Training Guide: Recording and Handling of Schedule 8 Drugs in Hospital Wards

Training guide
Recording and handling of

Schedule 8 drugs in hospital
wards
(including healthcare services and other patient care settings)
Contents page
 Objectives
 Introduction
 2011 changes to the Register
 Reasons for 2011 changes to the Register
 When and how to make entries in the Register
 What is in the Register Drugs of Addiction
 Explanatory notes
 Using the index page
 General notes on the record of drugs received administered or supplied page
 Using the record of drugs received administered and supplied page
 Amount discarded column
 General notes on the record of drugs destroyed page
 Using the record of drugs destroyed page
 Who can destroy and who can witness the destruction of a Schedule 8 (S8) drug
 S8 balance checks
 Reporting discrepancies in the Register
 General information on S8 drugs
 Related Information and further enquiries
Objectives
The objectives of this PowerPoint presentation are to provide information on:
 records which are required to be maintained in the Register Drugs of Addiction HA 14
 how to use the Register Drugs of Addiction HA 14
 2011 changes to the Register Drugs of Addiction HA 14
 reporting discrepancies in the Register
 other
Return to previous slide

Introduction
 S8 requirements are detailed in the Poisons Act 1964 and the
Poisons Regulations 1965.
 WA Health is responsible for administering the Poisons Act 1964 and its
Regulations which includes the monitoring of S8 drugs.
 S8 drugs are also referred to as drugs of addiction or drugs of dependence.
 S8 drugs are addictive and can be abused and diverted.
 To manage the use of S8 drugs in WA there are controls over the

prescribing and record keeping of S8 drugs that are supplied or used.
 A Register must be maintained when a S8 drug is supplied, obtained stored

or used (Regulation 44).
 The Register Drugs of Addiction HA 14 is the Register which is used in

hospital wards, healthcare services and other patient care settings to record
S8 drugs transactions.
2011 changes to the Register HA 14
 more detailed explanatory notes
 revised index page
 inclusion of an “amount discarded” column in the

record of drugs received administered or supplied page
 signature columns requiring authorised persons to sign and print

their names in the
record of drugs received administered or supplied page
 addition of a record of drugs destroyed page

Reasons for 2011 changes to Register
 improve ease of use
 enhance accountability
 minimise the risk of errors

When and how to make entries in the
Register
 An entry is to be made in the Register when a S8 drug is used, received, supplied or
stored.
 An entry is to be made when the transaction occurs.
 Person recording an entry in the Register must sign and print their name.
 Entries made in the Register must be in ink. Correction fluid is not to be used.
 Entries in the Register are not to be obliterated, deleted or altered.
 Incorrect entries or errors should be corrected with a marginal or footnote which is

initialled and dated.
 An entry can be corrected by making an entry on a subsequent line.

What is in the Register drugs of
addiction HA 14 ?
 explanatory notes
(located on the inside cover page)
 index page
(located on the first two pages of the Register)
 record of drugs received administered or supplied page

(located after the index pages)
 record of drugs destroyed page

(located on the last two pages of the Register)

Explanatory notes
Revised
explanatory
notes 2011

Explanatory notes
Item 8 is new in the explanatory

notes to highlight:
 the record of drugs destroyed page
 who can destroy an S8 drug
 who can witness the destruction of an S8 drug

Worked example of index page
revised index page 2011

Using the index page continued
Record:
 drug name
+
 brand name
to minimise the risk of confusion and error

 Record
 Release type:
immediate release
sustained release
controlled release etc
 Form:
tablets
injections
capsules
suppositories etc
 Strength: mg, mg/mL, microgram etc

Record
 page number
This is the page number of the record of drugs received

administered or supplied page where the drug’s
transactions details will be entered.
When a record of drugs received administered or

supplied page recording an individual drug’s transaction
is full a new page is to be commenced. In the Index
page a line is put through the completed page number
and the new page number is recorded.
General notes on the record of drugs
received administered or supplied page
 Record one drug per page (ensure that an entry for the drug has been made
in the index page).
 Recording one drug per page ensures that there is a running balance of the
stock on hand of that drug.
 Date is the day the transaction occurred and should be recorded at the time
the transaction occurred.
 Actual destruction transactions of S8 drugs should not be entered in this

part of the Register.

Worked example of a record of drugs
Revised record of
drugs received,
administered or
supplied page 2011 Return to previous slide
Using the record of drugs received,
administered or supplied Page
Record:
 drug details as recorded in the index page

Using the record of drugs received
administered or supplied page
For incoming stock record:
 amount (number of capsules/tablets/injections,

volume of oral liquid etc)
 requisition number (located on top left hand side of

requisition form)
administered or supplied page continued
Identifying details is a description of the

transaction where you record:
 Supplier (if stock received ie “ex pharmacy”
or
 Patient name in full (if dose administered or

supplied).
or
 DD check (if safe check undertaken)
or
 Stock to be destroyed (stock should be

labelled ‘to be destroyed’ and placed to the
side in the safe to await destruction by
authorised person).
Administration of S8 drugs
For patient administration
Record:
 time dose given
 dose administered (record in mg, microgram, mL etc)
 amount discarded (record in mg, microgram, mL etc)

‘Amount
discarded’  amount issued from stock (record in mg, microgram, mL etc)
column new in
2011
Amount discarded column
Amount issued from stock – Dose administered
=
Amount discarded
 Amount discarded only relates to products such as injections

and infusions where the sterility of the product is compromised
 All other formulations where only part of a product is used the

remainder is to be accounted for in the balance.
 If the remainder of the product for example half a tablet is

unusable, then it should be recorded in the record of drugs
received, administered or supplied page that it is to be
destroyed. It should then be labelled and put aside in the safe to
await destruction.
 See record of drugs destroyed section for further information

on destroying of S8 drugs.
Supply of S8 drugs
Supply of S8 drugs:
 must only be done by an authorised person such as a medical practitioner or

pharmacist
 must be recorded in the Register
 may be done when the pharmacy is closed
 must be appropriately packaged and labelled in accordance with the Poisons

Regulations 1965
Note: supply = handing the appropriately packaged and labelled S8 drug to the
patient to take home
Record
 The balance as the physical amount

ie, number of tablets, capsules,
injections etc)
Note: A balance should be maintained

at all times.
For identification purposes the person authorised to

complete the ‘Administered, supplied or received by’
column must:
 Sign name
 Print name
Registered nurses should complete this column if

they:
 receive S8 drugs onto the ward

or
 administer a S8 drug to a patient in accordance
with the instructions on the medication chart.
Medical practitioners should complete this column if

they:
 supply an S8 drug to a patient.

administered or supplied Page
continued
For identification purposes, the person authorised
to witness the administration, supply or receipt of
S8 drugs must:
 sign name
 print name
The witness can be from the same professional

category as the person completing the
‘Administered, supplied or received by’ column.
When commencing a new page to
record an S8 drug’s transactions
(following the page used previously
being full), record:
 balance of the page used

previously
 page number the balance is being

transferred from.
When the page is full record:
 S8 drug’s current balance
 page number of the new record of drugs

that will record the drug’s transactions.
Note: a new page number is to be

recorded in the index page
General notes on record of drugs
destroyed page
 Partially used contents of an S8 drug e.g. in the form of an injection, vial or
infusion are not to be recorded in the record of drugs destroyed page.
The amount to be discarded should be recorded in the ‘amount discarded’
column on the same line as the entry for the dose administered in the
records of drugs received administered or supplied page.
 There are no individual drug pages to record the destruction of S8 drugs.

They are all recorded in the same page of the record of drugs destroyed.

Worked example of record of drugs
destroyed
New page in Register

2011

Using the record of drugs destroyed cont.
Record:
 name, form and strength of drug
 amount destroyed (eg number of injections,

number of tablets)
Note: All S8 drugs destroyed are recorded on

the same page of the record of drugs
destroyed page. There is not an individual
page for each type of S8 drug destroyed.
Using the record of drugs destroyed
page
Page number refers to the page

Reason for destruction includes: in the ‘Record of drugs received,
administered or supplied’ where
 damaged Stock there is an entry recording that
 expired Stock the S8 drug is to be destroyed.
Using the record of drugs destroyed
page continued
For identification purposes the authorised

person must:
 sign name
 print name
Note: The authorised person destroying the

S8 drug cannot be from the same
professional category as the authorised
witness unless the destruction and
witnessing is done by two pharmacists.
Who can destroy and who can witness
the destruction of an S8 drug?
Authorised person + Authorised witness
Authorised person Authorised witness
registered medical director of nursing or registered pharmacist

practitioner
registered pharmacist registered pharmacist, registered medical
practitioner or director of nursing
director of nursing registered medical practitioner or registered
pharmacist
registered veterinary registered pharmacist, registered medical
surgeon practitioner or director of nursing
registered dentist registered pharmacist, registered medical

practitioner or director of nursing

If the actual balance on hand does not equate to the
recorded balance in the Register then the discrepancy
needs to be identified.
S8 balance checks  Identified discrepancy:

an entry is to be made in the Register to show the
reason for the discrepancy and the balance is to be
amended.
 Unidentified discrepancy:
an entry is to be made in the Register to indicate that the
discrepancy has not been identified but is being
investigated. The balance is to be amended to reflect the
actual balance on hand and the discrepancy is to be
reported to the CEO.

Reporting discrepancies in Register
 Any discrepancies in the Register are to be notified to the CEO of the Department of
Health via the Corporate Governance Directorate within 24 hours of becoming aware
of the discrepancy.
 Discrepancies should be reported via the approved notification form.
 All discrepancies should be reported and followed up including identifying the reason
for the discrepancies and documenting and reviewing the reasons for the
discrepancies.
 The Pharmaceutical Services Branch of the Department of Health which is responsible

for the monitoring of S8 drugs will be advised via the Corporate Governance
Directorate of the discrepancy.
 Other misconduct issues such as ordered stock not being received, possible misuse or
diversion of the S8 drugs or concerns regarding entries in the Register should also be
reported to the Corporate Governance Directorate.
 The poisons permit holder of the S8 drugs should be advised of all investigations
requiring follow up and review.

Reporting discrepancies in the Register
The approved form for reporting a discrepancy in the Register is to be

completed and forwarded to Corporate Governance Directorate by:
Facsimile to (08) 9222 2398
Email: accountability@health.wa.gov.au
Refer to Operational Directive OD 0140/08 for further information.

General information on S8 drugs
The following provides information on other features of S8 drugs including:
 the names of S8 drugs
 how to store S8 drugs
 inventory of S8 drugs
 patient’s own S8 medicine

S8 drugs
S8 drugs are those drugs listed in Schedule 8 of the Standard for the Uniform
Scheduling of Medicines and Poisons (SUSMP) and include:
 morphine
 pethidine
 fentanyl
 hydromorphone
 ketamine
 oxycodone
 pentazocine
 methadone
 buprenorphine
 dexamphetamine
 methylphenidate

How to store S8 drugs
 All S8 drugs in hospital wards should be stored in a lockable cupboard in

the ward or in a lockable portion of a cupboard in the ward where the area
has been designated solely for the purposes of storing S8 drugs.
 The registered nurse in charge of a ward where S8 drugs are stored is

required to keep the key to the cupboard or the lockable portion of the
cupboard in their personal possession. They are required to ensure that the
cupboard or lockable portion of the cupboard is locked at all times except
when stock is being removed or placed into the cupboard or lockable portion
of the cupboard.

Inventory of S8 drugs
An inventory of S8 drugs should be done:
 at intervals of not more than one month

or
 by persons handing over control of the S8 drugs
and
 by persons taking control of the S8 drugs
If an inventory does not balance i.e. the physical balance does not
match the actual recorded balance in the Register then the
discrepancy should be identified. If the discrepancy cannot be
identified then the person in charge of the S8 drugs at the time
is required to advise the CEO in writing immediately.
Refer to reporting discrepancies in Register for further information.

Patient’s own S8 medicine
S8 medicine brought in by a person who is admitted to hospital should be:
 stored in the ward where the patient is located

 recorded in the ward where the patient is located
in accordance with hospital policy.

Related information and further
enquires
Related information
 Operational Directive OD 0141/08

Code of practice for the handling of S8 medicines (drugs of addiction) in hospital and
nursing posts.
 Operational Directive OD 0140/08

Reporting of S8 medicine stock discrepancies in WA public hospitals including
notification of S8 stock discrepancy form.
Further enquiries
 For further enquiries on the regulatory requirements of S8 drugs contact

Pharmaceutical Services, Department of Health on 9222 6883.

Training Guide: Recording and Handling of Schedule 8 Drugs in Hospital Wards

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Training guide

Recording and handling of

The objectives of this PowerPoint presentation are to provide information on:

 records which are required to be maintained in the Register Drugs of Addiction HA 14

 how to use the Register Drugs of Addiction HA 14

 2011 changes to the Register Drugs of Addiction HA 14

 reporting discrepancies in the Register

Return to previous slide

 S8 drugs are also referred to as drugs of addiction or drugs of dependence.

 S8 drugs are addictive and can be abused and diverted.

 To manage the use of S8 drugs in WA there are controls over the

 A Register must be maintained when a S8 drug is supplied, obtained stored

 The Register Drugs of Addiction HA 14 is the Register which is used in

 more detailed explanatory notes

 revised index page

 inclusion of an “amount discarded” column in the

 signature columns requiring authorised persons to sign and print

 addition of a record of drugs destroyed page

Return to previous slide

 improve ease of use

 minimise the risk of errors

Return to previous slide

 An entry is to be made when the transaction occurs.

 Entries in the Register are not to be obliterated, deleted or altered.

 Incorrect entries or errors should be corrected with a marginal or footnote which is

 An entry can be corrected by making an entry on a subsequent line.

Return to previous slide

 record of drugs received administered or supplied page

 record of drugs destroyed page

Return to previous slide

Return to previous slide

Item 8 is new in the explanatory

 the record of drugs destroyed page

 who can destroy an S8 drug

 who can witness the destruction of an S8 drug

revised index page 2011

Return to previous slide

to minimise the risk of confusion and error

 Strength: mg, mg/mL, microgram etc

This is the page number of the record of drugs received

When a record of drugs received administered or

 Actual destruction transactions of S8 drugs should not be entered in this

Return to previous slide

 drug details as recorded in the index page

For incoming stock record:

 amount (number of capsules/tablets/injections,

 requisition number (located on top left hand side of

Identifying details is a description of the

 Supplier (if stock received ie “ex pharmacy”

 Patient name in full (if dose administered or

 DD check (if safe check undertaken)

 Stock to be destroyed (stock should be

For patient administration

 time dose given

 dose administered (record in mg, microgram, mL etc)

 amount discarded (record in mg, microgram, mL etc)

 Amount discarded only relates to products such as injections

 All other formulations where only part of a product is used the

 If the remainder of the product for example half a tablet is

 See record of drugs destroyed section for further information

 must only be done by an authorised person such as a medical practitioner or

 must be recorded in the Register

 may be done when the pharmacy is closed