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MAT Health ClinicPOLICY NUMBER: MHC/SSHM001

NAME: Stock Control, Storage and Safe Handling of Medications

APPROVED BY: Practice Principal

SECTION 1 – INTRODUCTION

PurposeThe aim of this policy is to inform all staff that have any involvement with stock and medications, of the correct procedures for the safe handling, ordering, storage and safe disposal.

ScopeThis procedure applies to all MAT Health Clinic Management and staff.

IntroductionMedications, vaccines, medical supplies, office stationery and other sundry item relating to the administration of the MAT Health Clinic.

All employees are required to document and maintain an effective system to ensure that medications are handled in a safe and secure manner.

Section 2 – PolicyThe prescription, supply and administration of medications is strictly regulated for individual and public safety and quality of care. Approved providers and their delegated

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MAT Health Clinicmanagers and staff must comply with relevant legislation such as state and territory drugs and poisons Acts (however titled).

All regulated health professions (including pharmacists, medical practitioners, nurse practitioners, registered and enrolled nurses) are subject to national, state and territory legislation and regulation governing their professions, including their roles in medication management. Health professionals also need to be aware of and comply with professional practice standards and guidelines.

This policy document outlines the mandatory legal and ethical aspects involved in the procedures for obtaining, recording, handling, storing, safe keeping, and safe disposal of medications.

It is to make clear that the supply, storage and disposal of medications within the organisation follows national standards and legislative requirements and;

To promote and support the safe and effective management of medications

Stock ControlMAT Health Clinic maintains strict inventory control for all is medications and vaccines. This inventory is actively managed and regularly reviewed for possible improvements in process or policy.

The key areas of management are: Inventory Management Order Management Delivery Management

Inventory ManagementThe electronic stock system allows staff to review actual inventory data over several years and develop reliable statistics and assumptions from that data. As a result, optimal stock numbers are reviewed regularly against historical usage and changes to that usage over time resulting in an adjustment to that inventory where required. Stock is actively managed by the senior nurse.

Order ManagementTo ensure consistency, the clinic nurse in charge or senior administrator are primarily responsible for requisitioning medications. This allows them to have control and accountability over what is ordered ensuring consistency in ordering practices and


MAT Health Clinicwastage rates. In addition MAT Health Clinic have developed and utilise an electronic system, for monitoring and managing all inventory.

This system generates order requirements based on predetermined stock levels for the clinic. These stock levels have been defined by the Practice Principle and are reviewed periodically for their appropriateness. The system produces inventory reports that indicate:

actual stock at the clinic, and product required to be ordered.

Only one general pharmacy requisition book or pre-printed current stock list may be held at the clinic at any given time and must be kept locked in a secure place.

Requisition books must be kept in the clinic for two years from the date of the last entry.

A requisition for medications or ‘top up’ order must be signed by one of the following members of staff:-

A medical officer A registered nurse

Delivery ManagementMAT Health Clinic receives two routine deliveries per week for the stock requiredThe delivery schedule is as follows:

Tuesday one delivery per day, delivery in the morning Friday one delivery per day, delivery in the morning

The clinic nurse in charge, or senior administrator must check the medications supplied against the original requisition and the delivery note for any discrepancies, when stock arrives and then sign for their receipt. If any discrepancies are identified the supplier must be contacted immediately.

Where Controlled Drugs are received, two nurses must check receipt and sign the pink copy of the requisition. Any errors must be recorded and countersigned by the witness and the supplier must be notified as soon as practicable. Controlled drugs receipts must also be entered in the Controlled Drugs register (CDR), along with the signatures of the person who has received them and the witness.

Storage of MedicationsTo ensure the safe use of medicines, vaccines and other healthcare products, MAT Health Clinic implement processes and systems that ensure the safe and efficient storage and distribution of medicines, and that minimise wastage of these products. The priority is to ensure that the product integrity is maintained.


MAT Health ClinicThe clinic nurse or senior administrator in charge is responsible for ensuring that sufficient stocks and supplies are available at all times and stored in accordance to legislative and manufacturer guidelines and monitored appropriately. In the event where storage conditions fall outside of the recommended range as specified by the manufacturer, the integrity and quality of the medication may become affected therefore the below storage conditions apply: .

Do not use perishable materials beyond their expiry dates Store in a safe place, away from the sight and reach of children Store in a dry and dust free atmosphere Keep medications in the containers they were dispensed in Adhere to temperature/refrigeration requirements Store in a locked storage facility, including any room, cupboard, fridge or drawer)

Safe storage of medicationsMedications must be stored according to the manufacturer’s recommendations, the majority of medications only require storage at room temperature, which is typically below 25° C.

Some other medications require refrigeration to ensure their viability and quality. These temperature-sensitive products include pharmaceuticals, clinical trial medicines and vaccines which require storage between +2° C and +8° C. The World Health Organization (WHO) recommends that special refrigeration storage conditions are checked and monitored regularly, and that appropriate date is recorded for refrigerated medications to ensure storage conditions are both preserved and within the allowable limits.

Refrigerated and ambient temperature medication guidelines Medications will usually be labelled clearly to indicate when they will require

refrigeration. A separate lockable medicine refrigerator must be available where medications

may require it. Food and pathological specimens must not be stored in the same fridge. Refrigerated medications must never be frozen


MAT Health Clinic A maximum /minimum thermometer must be available to monitor room and

refrigerator temperatures at least daily and be recorded on a room and fridge monitoring form (See below).

The room and fridge maximum and minimum thermometer(s) must be reset on a daily basis.

If the temperature range is exceeded it is the responsibility of the individual to report the incident and immediately seek advice from the Clinic Nurse or Senior Administrator.

Products requiring storage between 2-8ºC will be transported in a container able to maintain the cold chain.


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MAT Health ClinicVaccines It is essential that all vaccines are stored and transported in a way which preserves the cold chain.

National Vaccine Storage Guidelines - Strive for 5 - 2nd edition

Storage of Medical Gases All medical gases used in the MAT Health Clinic are licensed medications and are subject to the Australian Dangerous Goods Code. Staff that use medical gases in the course of their duties must be fully trained and be aware of related risks such as fire and manual handling. They must ensure that they follow their departmental instructions for the handling of medical gases; in addition the following precautions must also be observed.

The number of cylinders held as stock in any department should be as small as possible. Cylinders must be firmly secured at all times to prevent them falling over.

They should be stored under cover, preferably inside and not subjected to extremes of heat. Naked lights must not be allowed within the immediate vicinity of a cylinder.

No oil or grease should be applied to the cylinder or tap connector, therefore ensure hands are clean before handling cylinders. In particular ensure hands are adequately dried after the use of alcohol gel.

Segregate full and empty cylinders and separate the different gases within the store. Have warning notices posted prohibiting smoking and naked lights within the vicinity of the

store. Allow for a strict rotation of full cylinders to enable the cylinders with the oldest filling date to be used first.

The storage should be designed to prevent unauthorised access and to protect cylinders from theft.

Excessive force or any tools must not be used to open or close a cylinder valve. Cylinders with damaged valves and defective equipment must be labelled appropriately and

withdrawn from use and returned to the supplier for a replacement.


http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/IMM77-cnt

MAT Health Clinic

MAT Health Clinic Medications Cupboards and Security The MAT Health Clinic has a dedicated drug storage cupboard where medicines can be safely stored.

All medicines must be safely stored in a way that prevents unauthorised access. This means that drug storage cupboards in the MAT Health Clinic must be kept locked at all times. The Clinic nurse must hold the key.

Access to the room must be restricted to registered clinical staff and Practice Manager. The MAT Health Clinic has an approved S8 / Dangerous Drugs safe. Restricted S4 Medicines cannot be accommodated in the S8 / Dangerous Drugs safe, a secure lockable cupboard for storage of these medicines is acceptable.

Schedule 4 and Schedule 8 medicinesThe acquisition, use, storage and disposal of Schedule 4 and Schedule 8 medicines are subject to jurisdictional legislative requirements. For information on jurisdictional requirements refer to the drugs and poisons branch of the relevant jurisdiction:Australian Capital TerritoryPharmaceutical Services, ACT HealthTelephone: 02 6205 1700 Fax: 02 6205 0997Northern TerritoryPoisons Control, Department of Health & FamiliesTelephone: 08 8922 7341 Fax: 08 8922 7200New South WalesPharmaceutical Services Branch NSW Health Telephone: 02 9879 3214 Fax: 02 9859 5165QueenslandDrugs and Poisons Policy and Regulation, Environmental Health Unit, Queensland HealthTelephone: 07 3328 9310 Fax: 07 3328 9354South AustraliaPharmaceutical Services and Strategy, Department of HealthTelephone: 08 8204 1942 Fax: 08 8226 9837Tasmania Pharmaceutical Services Branch, Department of Health and Human Services, TasmaniaTelephone: 03 6233 2064 Fax: 03 6233 3904VictoriaDrugs and Poisons Regulation Group, Department of HealthTelephone: 1300 364 545 Fax: 03 9096 9168Western Australia Pharmaceutical Services Branch, Disaster Managements, Regulation and Planning Directorate, Department of Health, Western Australia Telephone: 08 9222 6883 Fax: 08 9222 2463

Storage of Medications for External Use Medications stored for external use should be clearly labelled and must be stored in a separate cupboard or, if space does not permit, on a separate shelf to medications for internal use. External

MAT Health Clinicuse refers to those medications used for application to the skin, teeth, mucosa of the mouth, throat, nose, eye, ear, vagina or anal canal. This does not include throat sprays, throat pastilles, throat lozenges, throat tablets, nasal drops, nasal sprays, nasal inhalations, teething preparations or dental gels.

Security Prescription pads and pages for computer-generated prescriptions Prescription pads and pages for computer-generated prescriptions are known to be misappropriated by patients (sometimes by staff members and family members) and used to create fraudulent prescriptions for drugs of dependence. These items should not be stored in unlocked areas or left in printers, where they might be subject to opportunistic theft.

Medical practitioners should also ensure that computer passwords are not known to, or likely to be guessed by, other people; the creation of fraudulent computer-generated prescriptions, by staff members, has been identified on a number of occasions.

The medical practitioner is responsible for making regular formal checks to ensure compliance with stock control and security procedures. Reporting Losses/MisuseThe loss or suspected loss, misuse or accidental damage of any medicinal product must be reported by the Practice Principle in line with the standard operating procedure for controlled drugs.

Safe Disposal of MedicationsUnwanted medicines can be returned to local pharmacies involved in the Return Unwanted Medicines (RUM) Project.

More information is available on the Return Unwanted Medicines (RUM) website

Destruction of Schedule 8 poisonsIf a medical practitioner wishes to destroy expired or unwanted Schedule 8 poisons, the destruction must be witnessed by a pharmacist, dentist, veterinary practitioner, nurse, nurse practitioner or another medical practitioner. Two nurses are not authorised to perform the task unless the principal person is a nurse practitioner. Both participants in the destruction must sign the corresponding record book.

Matters to be reportedThe Police and Chief Executive, of the relevant state or territory Department of Health must be notified when:

drugs or records are lost or stolen

MAT Health Clinic a medical practitioner has reason to believe a person has obtained Schedule 8 or Schedule

4 poisons (or prescriptions) by false pretences

The relevant state or territory department should also be notified of the loss or theft of prescription pads

ResponsibilityIt is the responsibility of all MAT Health Clinic employees to ensure that they remain informed regarding procedure that impact upon their work and duties.

SECTION 2 – GOVERNANCE

RELATED DOCUMENTATION

Document NameStock RegisterQuality Management and Procedure Manual

RESPONSIBILITY

Policy administrator Practice ManagerApproving Person Practice Principal

CHANGE HISTORY

Version Review date Approved by Description of Modifications1 01-Jan-2019 M. Evans Original Document