1. Training guide Reporting S8 and S4R medicine discrepancies in public hospitals

2. 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 Medicine Discrepancy and Loss (MD/L) Report form  Flow-chart: Managing and reporting medicine loss in public hospitals 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 pageReturn to last slide viewed

3. Table of contents Overview What’s new? What is a medicine discrepancy? Roles and responsibilities – hospital staff Roles and responsibilities – others Who is my Medication Incident Coordinator (MIC)? Flowchart Quick Guide: How to report a medicine discrepancyHow to report a medicine discrepancy Quick Guide: Medicine not located in 24 hoursMedicine not located in 24 hours Quick Guide: Outcomes of incident reviewOutcomes of incident review Quick Guide: After the incident reviewAfter the incident review Medicine discrepancy/loss report form Using the form Tips for completing the form Reporting multiple incidents Reporting after hours, long weekends and holidays Liquids Trend analysis Practice reviews What happens to reports Misconduct Case study: single discrepancy reporting Case study: reporting multiple discrepancies Case study: liquid discrepancies Where to go for further information

4. 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. Return to contents pageReturn to last slide viewed

5. 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. Return to contents pageReturn to last slide viewed

6. Roles and responsibilities – hospital Notifier 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 Reviewer Nominated 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. Return to contents pageReturn to last slide viewed

7. 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 Return to contents pageReturn to last slide viewed

8. 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 public hospitals – there is space for the MICs name to be recorded here.flowchart on Investigating and reporting medicine loss in public hospitals Return to contents pageReturn to last slide viewed

9.  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 Department of Health Operational Directives and Circulars Flowchart Return to contents pageReturn to last slide viewed

10. 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. Return to contents pageReturn to last slide viewed

11. Discrepancy identified  follow up checklist  medicine not located The 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. +2 4hr s 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. +7 2hr s Quick guide continuedQuick guide continued: Return to contents pageReturn to last slide viewed

12. Outcome of reviewExplanation No loss/medicine located Where the review identifies that there was no actual medicine loss. Example: where medication was administered but not recorded. Unexplained loss Where the review does not identify a cause for the discrepancy and the medicine has not been located. Explained loss: system/practice related Where the cause of the loss is identified (not misconduct) but the medicine has not been located. Explained loss: misconduct related 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. Outcomes of the incident review Quick guide continuedQuick guide continued: Return to contents pageReturn to last slide viewed

13. 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. +72 hrs 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 Quick guide continuedQuick guide continued: Return to contents pageReturn to last slide viewed

14. 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.Department of Health Operational Directives and Circulars Return to contents pageReturn to last slide viewed

15. 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. Return to contents pageReturn to last slide viewed

16. 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. Return to contents pageReturn to last slide viewed

17. 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. One formMultiple forms Time the discrepancy was identified Same time (e.g. during the same register balance check) Different times (balance checks done on different days) Discrepancy type Same type (e.g. loss or excess, imprest or dispensed) Different types (e.g. hospital imprest stock and patient’s own medicine) Location Same location (e.g. same ward) Different locations (e.g. different wards) Return to contents pageReturn to last slide viewed

18.  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 of your 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 be done. 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 +2 4hr s +7 2hr s Return to contents pageReturn to last slide viewed

19. 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)Policies and Guidelines Return to contents pageReturn to last slide viewed

20. 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. Return to contents pageReturn to last slide viewed

21. 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. Return to contents pageReturn to last slide viewed

22. 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 Return to contents pageReturn to last slide viewed

23. 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. Return to contents pageReturn to last slide viewed

24. 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 of discrepancies in Ward 1.  Liquid medicine discrepancy: Jacob Ladder notices that the Ordine ® liquid has run out early. Return to contents pageReturn to last slide viewed

25. Single medicine discrepancy Incident details Single medicine discrepancy Section 1: Incident details Medicine Discrepancy/Loss Report form Section 1 is completed by the person who notices the discrepancy (the Notifier). Return to contents pageReturn to last slide viewed

26. Single medicine discrepancy Section 1: Actions - Notify staff and follow up checklist Return to contents pageReturn to last slide viewed

27. Single medicine discrepancy Section 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? Return to contents pageReturn to last slide viewed

28. Single medicine discrepancy Section 2: Incident details Section 2 is completed by the Medication Incident Coordinator and the Incident Reviewer. Return to contents pageReturn to last slide viewed

29. Single medicine discrepancy Section 2: Incident review checklist Return to contents pageReturn to last slide viewed

30. Single medicine discrepancy Section 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. Return to contents pageReturn to last slide viewed

31. Multiple discrepancy report Section 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). Return to contents pageReturn to last slide viewed

32. Multiple discrepancy report Section 1: Actions – Notify staff and follow up checklist Return to contents pageReturn to last slide viewed

33. Multiple discrepancy report Section 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. Outcome: document the outcome of the follow up process. Was the medicine located? Has the register balance been corrected? Have any issues been identified? Return to contents pageReturn to last slide viewed

34. Multiple discrepancy report Section 2: Incident details Section 2 is completed by the Medication Incident Coordinator and the Incident Reviewer. Return to contents pageReturn to last slide viewed

35. Multiple discrepancy report Section 2: Incident review Return to contents pageReturn to last slide viewed

36. Multiple discrepancy report Section 2: Incident review continued Return to contents pageReturn to last slide viewed

37. Multiple discrepancy report Section 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. Return to contents pageReturn to last slide viewed

38. Multiple discrepancy report Section 2: Outcome continued Return to contents pageReturn to last slide viewed

39. Multiple discrepancy report Section 2: Outcome continued Printed form: Notifier to sign by hand Emailed form: ok to use HE number in sign off section. Return to contents pageReturn to last slide viewed

40. Liquid discrepancy Section 1: Incident details Reporting a liquid loss Section 1 is completed by the person who notices the discrepancy (the Notifier). Return to contents pageReturn to last slide viewed

41. Liquid discrepancy Section 1: Actions – Notify staff and follow up checklist Return to contents pageReturn to last slide viewed

42. Liquid discrepancy Section 1:Outcome, sign off and 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? Return to contents pageReturn to last slide viewed

43. Liquid discrepancy Section 2: Incident details Section 2 is completed by the Medication Incident Coordinator and the Incident Reviewer. Return to contents pageReturn to last slide viewed

44. Liquid discrepancy Section 2: Incident review checklist Return to contents pageReturn to last slide viewed

45. Liquid discrepancy Section 2: Outcome, notification and sign off Printed form: Notifier to sign by hand Emailed form: ok to use HE number in sign off section. Return to contents pageReturn to last slide viewed

46. 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 Return to contents pageReturn to last slide viewed