Training Guide for PDF - ww2.health.wa.gov.au

Training guideReporting S8 and S4R medicine discrepancies in public hospitals

Overview This Guide will set out the process for managing and reporting medicine

discrepancies in WA public hospitals (including private patients treated in public hospitals) and private facilities treating public patients.

It is based on: Operational Directive 0377/12 Reporting of medicine discrepancies in public hospitals and licensed private facilities which provide services to public patients in Western Australia

OD 0377/12 supersedes OD 0140/08 Reporting of Schedule 8 Medicine Stock Discrepancies in WA Public Hospitals and OD 0169/09 Reporting Medicine Losses in WA Public Hospitals.

The following documents are associated with the Operational Directive: Medicine Discrepancy and Loss (MD/L) Report form Flow-chart: Managing and reporting medicine loss in public hospitals

Relevant legislation/directives: Poisons Act 1964, Poisons Regulations 1965 Operational Directive OD 0215/09 Storage and Recording of Restricted

Schedule 4 Medicines.

Return to contents page

Table of contentsOverviewWhat’s new?What is a medicine discrepancy?Roles and responsibilities – hospital staffRoles and responsibilities – othersWho is my Medication Incident Coordinator (MIC)?FlowchartQuick Guide: How to report a medicine discrepancyQuick Guide: Medicine not located in 24 hoursQuick Guide: Outcomes of incident reviewQuick Guide: After the incident reviewMedicine discrepancy/loss report formUsing the formTips for completing the formReporting multiple incidentsReporting after hours, long weekends and holidaysLiquidsTrend analysisPractice reviewsWhat happens to reportsMisconductCase study: single discrepancy reportingCase study: reporting multiple discrepanciesCase study: liquid discrepanciesWhere to go for further information

What’s new?

defined roles and responsibilities: Notifier Medication Incident Coordinator Incident Reviewer

timeline for: initial follow up and reporting: 24 hours subsequent review if required: 72 hours

report form: lists the steps to take in initial follow up and subsequent review is an e-form: can type into fields, save form, email or print.


What is a “medicine discrepancy”?

A medicine discrepancy is a mismatch between the stock on hand and the register balance. It can be an excess or a loss.

This Operational Directive only applies to Schedule 8 and restricted Schedule 4 medicine discrepancies.


Roles and responsibilities – hospitalNotifier

The person who identifies a medicine discrepancy, undertakes initial follow up and reports discrepancies to the MIC and Corporate Governance Directorate within 24 hours.

Medication Incident Coordinator (MIC)A senior staff member who is responsible for receiving medicine discrepancy reports and nominating Incident Reviewers.A MIC may: be based at one central site and have responsibility for multiple locations (e.g. a

tertiary hospital plus annexes, or a WACHS region). have responsibility for a nominated area within a site (e.g. a specific ward or a group of

wards).The MIC retains reports, undertakes trend analysis, practice reviews and implements change to improve prevention and management of medicine discrepancies.

Incident ReviewerNominated by the MIC for each incident where initial follow up has not explained the discrepancy.The Incident Reviewer: undertakes additional review submits reports to Corporate Governance Directorate and the MIC

Hospital The Executive Director of each site must designate the MIC/s and must advise Corporate Governance Directorate of the position/s nominated and the contact details for the occupants of the positions.


Corporate Governance Directorate receives and reviews Medicine Discrepancy and Loss report forms enters reports into a database and conducts trend analysis of report data for misconduct

risk management purposes assesses and manages misconduct reports and investigations reports unexplained and misconduct related medicine losses to the Corruption and Crime

Commission.

Pharmaceutical Services Branch reviews all reports of Medicine Discrepancy and Loss investigates breaches of the Poisons Act 1964 and Poisons Regulations 1965.

Corruption and Crime Commission receives reports of misconduct related and unexplained medicine loss from Corporate

Governance Directorate assesses and investigates allegations of misconduct by public officers reviews misconduct management systems to work towards the prevention of misconduct.

Police receives reports of theft and poison loss investigates breaches of the Misuse of Drugs Act and Criminal Code.

Roles and responsibilities – others


Who is my Medication Incident Coordinator (MIC)?

The MIC will be a senior staff member who is responsible for receiving medicine discrepancy reports and nominating Incident Reviewers.

A hospital may have more than one MIC.

Your MIC might be:

the Director of Pharmacy or a senior pharmacist at your site

the Director of Nursing or the Nurse Director for your area

a medical practitioner or Unit director.

Check the flowchart on Investigating and reporting medicine loss in publichospitals – there is space for the MICs name to be recorded here.


The flowchart has been designed to: outline the steps involved in

identifying and reporting medicine discrepancies

show the staff members involved in the process.

It is recommended that the flowchart be printed and displayed in a prominent place to assist staff when a medicine discrepancy is identified.

The name of the Medication Incident Coordinator for the area can be noted on the chart to assist with reporting.

The flowchart can be downloaded via the Department of Health Operational Directives and Circulars webpage

Flowchart


http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12873

Quick guide: How to report a medicine discrepancy

If you notice a medicine discrepancy you must, within 24 hours:

1.Tell people – get your pharmacist, SRN/M and security officer on board. They may assist with follow up if needed.

2.Follow up the discrepancy. The Medicine Discrepancy/Loss report form has a checklist to guide you.

If you locate the medicine or find that there was no discrepancy:

you do not have to submit a report.

update the register balance (if required).

advise notified staff of the outcome of the follow up.

check your hospital policy to see if you need to do anything else.


Discrepancy identified follow up checklist

medicine not locatedThe Notifier (person who notices the discrepancy) must: correct the register balance.

Example text: DD check – discrepancy between balance and stock on hand complete Section 1 of the Medicine Discrepancy and Loss Report form send the report form to the Medication Incident Coordinator and Corporate

Governance Directorate within 24 hours of the incident being identified.

+24hrs

The Medication Incident Coordinator must: nominate an Incident Reviewer forward the Incident Reviewer the report form.

The Incident Reviewer must: confirm the initial findings conduct a review of the incident. The Medicine Discrepancy and Loss Report

form lists the steps that should be followed.

+72hrs

Quick guide continuedQuick guide continued:


Where the medicine has not been located and the cause of the loss can be attributed to, or can be reasonably suspected of being attributed to, misconduct.

Explained loss: misconduct related

Where the cause of the loss is identified (not misconduct) but the medicine has not been located.

Explained loss: system/practice related

Where the review does not identify a cause for the discrepancy and the medicine has not been located.

Unexplained loss

Where the review identifies that there was no actual medicine loss. Example: where medication was administered but not recorded.

No loss/medicine located

ExplanationOutcome of review

Outcomes of the incident review



The Incident Reviewer must: report theft and losses to the Police by phoning 131 444 report suspected misconduct to site Human Resources and Corporate

Governance Directorate advise pharmacy, nursing and security staff of the outcome of the review complete Section 2 of the Medicine Discrepancy/Loss Report form forward the report form to the Medication Incident Coordinator within 72

hours of the discrepancy being identified.

+72hrs

The Medication Incident Coordinator must: liaise with site Human Resources and Corporate Governance Directorate

regarding any misconduct report submitted complete Section 2 of the Medicine Discrepancy/Loss Report form forward the report to Corporate Governance Directorate within 72 hours of

the discrepancy being identified.

After the incident review



Medicine Discrepancy & Loss (MD/L) Report form

The form has been designed to: guide staff in the follow-up and review of medicine

discrepancies collect data to assess and manage medicine

discrepancies.

The form is broken into two sections:

Section 1: to be completed by the person identifying the discrepancy, the Notifier, within 24 hours of the discrepancy being identified.

Section 2: to be completed by the Medication Incident Coordinator and the Incident Reviewer within 72 hours of the discrepancy being identified.

Forms can be downloaded via the Department of Health Operational Directives and Circulars webpage.


http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12873

Using the report form

Print the form to fill in by hand or you can complete the form online.

When you fill in the e-form you can:

type directly into fields and can “Save As” for later

include more detail - fields will expand if required

add rows to report multiple incidents on one form and delete rows if required

print or email the completed form.

When you email the form:

you insert your HE number in the signature field

the fields you have completed will be locked against update

you can notify Pharmacy, senior Nursing and Security staff of the incident by including them in the email

scanned copies of relevant documents (e.g. registers or rosters) can be sent with the report form.


Tips for completing a report

If anyone else assisted in the process, include their names in the details section.

Talking with staff: Include the names of staff spoken to and any staff who were unavailable Document staff recollections about the incident and record any relevant activity

that occurred at the time the incident is thought to have occurred.

Outcome details: Complete the details sections separately for each discrepancy identified. Make

sure the report number is the same as in the Incident Details section of the form If something can’t be completed within 72 hours, note this down on the form and

then submit a supplementary report once it’s complete Always report to Police where required under the Poisons Regulations 1965 and

this Operational Directive. If the Police refuse to accept a report (this sometimes happens with unexplained losses) make a note in the Police Report Notes section of the report form and Corporate Governance will follow this up directly with Police.

Close the communication loop by notifying nursing, pharmacy and security staff of the outcome of review. If you are emailing the report form you can notify staff by including them on the email recipient list.


Reporting multiple incidents

You can use the e-form to submit multiple incident reports on the one form.

Only incidents from the same location, of the same type and identified at the same time should be reported on the one form.

Different locations(e.g. different wards)

Same location(e.g. same ward)Location

Different types(e.g. hospital imprest stock and patient’s own

medicine)

Same type(e.g. loss or excess, imprest or dispensed)Discrepancy type

Different times(balance checks done on different days)

Same time(e.g. during the same register balance check)

Timethe discrepancy was

identified

Multiple formsOne form


When a medicine discrepancy is noticed, the initial follow up and reporting must be completed within 24 hours.

This may mean completing the follow up process before the end ofyour shift if you are not rostered on again the following day.

Talk with your SRN/M and pharmacist – they may be able to assist in the follow up process.

When subsequent review is required this should be completed within 72 hours of when the incident was first noticed.

If the incident is reported to the Medication Incident Coordinator after hours or at the start of a long weekend, the review process may not be fully complete within the 72 hour time period. If this happens, a report should still be submitted within 72 hours – just note in the report which tasks have been completed and which are still to bedone. Submit an update once the review is complete.

If staff are unavailable for interview or are on leave during the review process, note this is the report and submit an update once they have been interviewed.

After hours, long weekends and holidays

+24hrs

+72hrs


Liquids It is recognised that there are particular issues relating to

balance discrepancies in liquids.

All liquid discrepancies must be reported. There is no acceptable level of liquid loss.

To reduce the risk of balance discrepancies: Use only one bottle at a time. In addition to routine stock checks, liquids should also

be reconciled at the end of each bottle using a syringe.

Use oral dispensing syringes and a bung in the bottle. Pharmacies to ensure the supply of the smallest

commercially available quantity of S8 medicines to wards. Pharmacies should not repackage liquids into smaller bottles.

Relevant document: Guidance note: Measurement of S8 oral liquids (can be downloaded online under Policies and Guidelines)


http://www.public.health.wa.gov.au/cproot/3465/2/S8_Oral_Liquid_Guidance_Note.pdf

Trend analysis

Performed by: the Medication Incident Coordinator

Looking for: repeating WHO, WHAT, WHEN, WHERE

Purpose: to identify a common cause of, or contributor to, medicine discrepancies that occurs across multiple incidents.

When trends are identified that contribute to medicine discrepancies changes should be implemented to address the risk.

Example: Multiple reports of a particular medicine going missing from ICU Resuscitation trolleys which, once identified as a trend, may lead to the removal of those medicines from the trolleys.

Summary information of reports submitted from your site may be requested from the Corporate Governance Directorate to assist Medication Incident Coordinators when undertaking trend analysis.


Practice reviews

Performed by: the Medication Incident Coordinator Looking for: deviations from standard practice or areas where standard

practice is deficient in preventing medicine discrepancies from occurring. Purpose: to identify areas for change and provide evidence for practice

change where required.

Changes may include:

policy/process review

performance management

in-service or staff training

identifying and implementing the use of tools to assist best practice.

Example: Reports of stock imbalance in liquids may be reduced by the routine use of oral dosing syringes.


What happens to reports?

Once reports reach Corporate Governance Directorate:

Each individual report is assessed to determine if additional investigation is required. Reviewers are looking for misconduct or breaches of the Poisons Act 1964 or Poisons Regulations 1965.

All reports of unexplained medicine loss and misconduct related loss are forwarded to the Corruption and Crime Commission (CCC).

The CCC may require additional information to be obtained or investigation conducted.

Notifier Corporate Governance Directorate

Pharmaceutical Services Branch

Corruption and Crime

Commission

Medication Incident Coordinator

Incident

reviewer

Section 1- MD/L Report form

Discrepancy identified

Follow up checklist

Medicine not located


Misconduct

Misconduct should be reported to Corporate Governance Directorate as soon as possible.

Reporting of misconduct cannot be delayed while internal investigations are carried out.

Corporate Governance Directorate is available to conduct training on misconduct identification and reporting.

Relevant documents: Operational Directive OD 0323/11 WA Health Misconduct and

Discipline Policy Misconduct and discipline guidelines: metropolitan health service and

WA country health service staff.


Case studies

Single medicine discrepancy: Betty Browne notices there is a hydromorphone tablet missing from the S8 locked cupboard in Emergency.

Multiple medicine discrepancies:June Jones does a register balance check and notices a number ofdiscrepancies in Ward 1.

Liquid medicine discrepancy:Jacob Ladder notices that the Ordine® liquid has run out early.


Single medicine discrepancyIncident detailsSingle medicine discrepancySection 1: Incident details

Medicine Discrepancy/Loss Report form

Section 1 is completed by

the person who notices the discrepancy (the Notifier).


Single medicine discrepancySection 1: Actions - Notify staff and follow up checklist


Single medicine discrepancySection 1: Outcome, sign off, submission

Outcome: document the

outcome of the follow up process.

Was the medicine

located? Has the register

balance been corrected? Have any issues been

identified?


Single medicine discrepancySection 2: Incident details

Section 2 is completed by the Medication

Incident Coordinator

and the Incident Reviewer.


Single medicine discrepancySection 2: Incident review checklist


Single medicine discrepancySection 2: Outcome, notification and sign off

Printed form: Notifier to sign by hand

Emailed form: ok to use HE number in sign off section.

If WA Police will not accept a report (this sometimes happens for unexplained losses), make note on the report form and Corporate Governance Directorate will follow up directly with Police.


Multiple discrepancy reportSection 1: Incident details

Using the report form for multiple medicine discrepancies

Report Number:automatically

generated within the report form. Outcomes must

match the correct report number.

Section 1 is completed by the

person who notices the

discrepancy (the Notifier).


Multiple discrepancy reportSection 1: Actions – Notify staff and follow up checklist


Multiple discrepancy reportSection 1: Outcome

Complete this section separately for each medicine discrepancy identified.

Make sure that the Report Number is the same as in the Incident Details section.



Was the medicine



identified?


Multiple discrepancy reportSection 2: Incident details





Multiple discrepancy reportSection 2: Incident review


Multiple discrepancy reportSection 2: Incident review continued


Multiple discrepancy reportSection 2: Outcome

Complete this section separately for each medicine discrepancy identified.

Make sure that the Report Number is the same as in the Incident Details section.


Multiple discrepancy reportSection 2: Outcome continued


Liquid discrepancySection 1: Incident details

Reporting a liquid loss

Section 1 is completed by

the person who notices the discrepancy (the Notifier).


Liquid discrepancySection 1: Actions – Notify staff and follow up checklist


Liquid discrepancySection 1:Outcome, sign off and submission



Was the medicine



identified?


Liquid discrepancySection 2: Incident details





Liquid discrepancySection 2: Incident review checklist


Liquid discrepancySection 2: Outcome, notification and sign off




Further information and assistance: Medication Incident Coordinator for your area

Pharmaceutical Services Branch (8.30am to 4.30pm Monday to Friday)Phone: 9222 6883

Corporate Governance Directorate (24/7)Phone: 1800 000 224

Human Resources for your site


Training Guide for PDF - ww2.health.wa.gov.au

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