Schedule 4 and Schedule 8 poisons in residential aged care facilities
Who can possess Schedule 4 and Schedule 8 poisons
The vast majority of medicines used in residential aged care services are supplied on prescription for administration to specific patients – in the same way that medicines are supplied for a person in private residential accommodation.
Accordingly, any person who has the care of (or is assisting in the care of) a resident for whom a medicine has been supplied on prescription could be authorised to possess that medicine for the specific purpose for which it was supplied. In a residential aged care service, such a person may be a nurse or a personal care worker.
From 1 July 2010, s. 136 of the Schedule to the Health Practitioner Regulation National Law (Victoria) Act 2009 replaced a similar provision in s. 85 of the Health Professions Registration Act 2005. Section 136 of the Schedule states that ‘A person must not direct or incite a registered health practitioner to do anything, in the course of the practitioner’s practice of the health profession, that amounts to unprofessional conduct or professional misconduct’.
High-level residential care situations – medicine administration
Management of medication by registered nurses
Where a resident in an aged care service is receiving high-level residential care, the Act specifies that the administration of Schedule 4 or Schedule 8 poisons to that resident must be managed by a registered nurse in accordance with the relevant code for guidance (if any) issued by the Nursing and Midwifery Board of Australia.
The Nursing and Midwifery Board of Australia has not yet indicated whether it intends to develop any guidance material in this area. The code issued by the Nurses Board of Victoria was repealed with effect from 31 May 2010.
Compliance with the legal requirement to ensure that each high-care resident’s medication is managed by a registered nurse may occur in a variety of ways. Compliance with this document will demonstrate compliance with the Act. An enrolled nurse cannot manage the administration of medicines to high-care residents.
The registered nurse with overall responsibility for management of medication must be readily identifiable to service staff, and able to be contacted by the Drugs and Poisons Regulation branch (DPR). It is expected that the position will be formalised in the service’s organisational framework and role description, and that staff are aware of that registered nurse’s role.
The registered nurse must be free from coercion, and have the necessary resources to manage the medication in accordance with their professional judgement and applicable professional nursing standards – for example, in regard to delegation and supervision.
Delegation of administering medicines
The registered nurse who is managing the administration of medicines to residents could delegate the routine supervision of other workers to whom they have delegated the task of administering medicines. This is a judgment for the registered nurse that must be exercised in accordance with professional nursing codes or guidelines for supervision and delegation.
As in all other aspects of nursing professional activity, a nurse is accountable for their professional decisions and actions. A nurse must demonstrate that delegation decisions have been properly made in accordance with professional practice guidelines, and that appropriate supervision and monitoring arrangements have been put in place and followed. The worker to whom a task is delegated is also held accountable to the extent of their training, and for following the systems and procedures required.
A registered nurse may only delegate the administration of medicines to someone appropriately qualified to administer medicines. This means that registered nurses may use their professional judgment about whether to administer medicines themselves, or to delegate the administration to someone with appropriate qualifications or scope of practice to administer medicines by the specified route.
Enrolled nurses (who do not hold a qualification in medicines administration approved by the Nursing and Midwifery Board of Australia) and personal care workers (with appropriate medicines administration training) may, in some circumstances, be competent to administer medicines under the delegation of a registered nurse. If a registered nurse judges that an enrolled nurse or personal care worker is not appropriately qualified to administer medicines to a high-care resident, they should administer the medicines themselves or delegate to appropriately qualified personnel. Appropriate supervision must be provided.
Nurse administration of Schedule 4 and Schedule 8 poisons
Where a nurse (not including an enrolled nurse who does not hold a board-approved qualification in medicines administration) is required to administer Schedule 4 or Schedule 8 poisons, r. 47 requires the nurse to first refer to authoritative instructions in the form of:
- written instruction of a medical practitioner (the most common option)
- oral instructions of a medical practitioner if, in the opinion of the medical practitioner, an emergency exists (for example, telephone orders)
- written transcription of the emergency instructions by the nurse who received them
- directions for use on a container supplied by a medical practitioner or pharmacist (for example, administration of a person’s own lawfully supplied medication).
Some residential aged care services have protocols that detail when a nurse may initiate treatment with specified medicines other than Schedule 4 or Schedule 8 poisons. This is a matter of liability and policy, rather than of drugs and poisons legislation.
It is anticipated that a resident not requiring high-level care is more likely to be personally involved in the management and administration of their own medicines, with assistance as required.
High-level aged care – storage of, access to and destruction of Schedule 4 and Schedule 8 poisons
Storage of, and access to, Schedule 4 and Schedule 8 poisons
- Schedule 4 poisons must be stored in a lockable facility.
- Schedule 8 poisons must be stored in a lockable room and/or in a lockable storage facility that is firmly fixed to a floor or wall. A steel drug cabinet is no longer mandated, because of the increased prevalence of dose administration containers. However, a steel drug cabinet:
- is strongly recommended for the storage of Schedule 8 poisons in original containers
- is strongly recommended for the storage of Schedule 8 poisons that cannot be packed into dose administration containers
- is required for the storage of Schedule 8 imprest drugs, where a health services permit is held
- may be required (for example, for larger quantities of Schedule 8 poisons), if directed by the DPRG.
- Facilities for the storage of Schedule 4 and Schedule 8 poisons must be locked to prevent unauthorised access.
Records of transactions
Records of all administrations of Schedule 4 and Schedule 8 poisons must be true and accurate, retained in a readily retrievable form for 3 years, and produced, on demand, in writing to an authorised officer of the DPRG. (See r. 40 for details that must be recorded.)
For Schedule 8 poisons, a separate record (for example, a drug register or administration book that shows the true and accurate balance remaining after each transaction) is required (r. 41), except where a Schedule 8 poison has been supplied on prescription for a specific person in tamper-evident compartments of a suitably labelled dose administration container.
Destruction of Schedule 8 poisons
Regulation 51 authorises a nurse to act as the witness when a Schedule 8 poison is to be destroyed by a medical practitioner, nurse practitioner, pharmacist or dentist. Note: This does not mean that two nurses may destroy Schedule 8 poisons.
To clarify the situation relating to an accepted and necessary practice, this regulation specifically authorises a nurse to destroy (for example, discard) the remaining, unused contents of a previously sterile container (for example, a partially used ampoule), provided that the nurse makes an appropriate record. Note: As a suitably qualified person might not be available, a witness is not mandated. However many establishments have a policy that requires a witness if another nurse is available.
Health services permit to obtain ‘imprest drugs’
Some residential aged care services choose to obtain a health services permit (HSP), for which an annual fee must be paid, to enable them to obtain medicines that have not been prescribed for specific patients, so that selected medicines are readily available for immediate administration.
Each HSP contains conditions that are specific to the type of health service provided and refers to a poisons control plan, which details how the medications will be managed. For all relevant application forms, details of fees, and poisons control plans and instructions on how to complete them, see ‘Health services permit’.
The following issues relate only to matters associated with the management of imprest stock.
Most medicines in residential aged care services are supplied on prescription for specific patients. However, if a facility holds a current HSP, Schedule 4 and Schedule 8 poisons may be supplied (without prescription) so that the medicines are available for urgent administration, to any patient, in accordance with instructions of a medical practitioner. Such medicines are referred to in this document as imprest drugs.
A pharmacist is considered to have supplied imprest drugs when possession of, control of or access to the drugs is transferred to nurses at the aged care service. When a payment occurs is irrelevant to when supply is said to have occurred.
Steps to obtain imprest drugs
The permit holder (that is, the aged care service) should provide the pharmacy with a copy of their HSP, to demonstrate that the service holds a current permit and to identify the poison schedules of the medications that may be obtained.
When an imprest drug is ordered, the pharmacist may supply the drug in accordance with r. 15(1)(f) and must make a record of the transaction. Imprest drugs are not supplied on prescription, so the pharmacist need not attach additional labels to the original containers.
The permit holder should store imprest drugs separately from medicines supplied on prescription and should manage them as described in the approved poisons control plan for the HSP.
When a nurse has a medical practitioner’s written or verbal instructions to administer an imprest drug to a patient, the nurse may remove the required dose(s) of medicine from the imprest store and must make a record of the transaction.
If the medical practitioner provides a prescription authorising the pharmacist to supply the medicine for the patient, the pharmacist must supply the quantity specified on the prescription, label the corresponding container in the manner described in r. 29 and make a record of the transaction. It is not acceptable to attach a dispensing label, corresponding to the subsequent prescription, to the container that was removed from the imprest store.
The container from which the initial dose(s) of an imprest drug was obtained will then contain fewer doses and should be returned to the imprest store.
Regulation 45 makes it an offence to administer drugs obtained on prescription to any person other than the person named on the prescription. Hence, a container of medicine obtained on prescription must not be used to replace a container that was removed from the imprest store.
A replacement container of an imprest drug may be supplied when the progressively reducing number of doses of the drug necessitates replenishment.