Background

Drug and Therapeutics Committees must implement local procedures in settings where a registered nurse/midwife is required to administer a Schedule 8 medication in an isolation room where a second person check cannot feasibly be undertaken.  

The local procedure must mitigate the risks of medication error and diversion. Use of devices such as infusion pumps is to be described in the local protocol. 

Current policy on Schedule 8 medication drug register witness and recording 

NSW Health PD2013_043 Medication Handling in NSW Public Health Facilities requires all Schedule 8 medication accessed from the drug safe/cabinet by a registered nurse/midwife (RN/RM) to be witnessed by a second person (witness). The drug register transaction must record either:

1. the immediate administration to a patient by the same RN/RM and witness, or 
2. the supply to another authorised practitioner to administer to a patient, such as another RN/RM or an authorised prescriber (for example an anaesthetist), or
3. the supply of medication dispensed (with a label) for discharge or for an outpatient, or 
4. the transfer of a Schedule 8 medication to another patient care area. 

Option 2 (in bold) is relevant for the supply of the medication to a RN/RM in an isolation room without a second person check. 

Current policy on second person Schedule 8 medication checks

1. NSW Health PD2013_043 Medication Handling in NSW Public Health Facilities requires (in section 7.7) that a second person check should be used before all Schedule 8 medications and the following other medications are administered (other than by an authorised prescriber) as determined by relevant NSW Health policies and local protocols and procedures:
• doses administered by injection
• doses administered to children up to their 16th birthday.
2. Hydromorphone is a high risk medicine in NSW Health PD2019_058 High-Risk Medicines Management Policy. The policy states (see page 12) that a second person check must be employed when administering hydromorphone.   

Safe Schedule 8 medication administration without a second person check at the bedside

A RN/RM and witness remove stock from a drug safe and make the drug register entry in accord with the dose required on the medication chart, and both persons then witness the supply to the separate RN/RM in the isolation room who may then administer the medication without a second person check at the bedside. 

The RN/RM in the isolation room administering the medication must:

1. record the administration in the patient’s medication chart or eMeds system
2. dispose of any unwanted portion of the dose in a sharps container in the isolation room and document this discard in the patient’s health care record (as applicable in the circumstance)
3. discard the remaining portion of discontinued or replaced medications such as infusions in a safe manner that renders the drug unrecoverable and document the amount discarded in the patient’s health care record (as applicable in the circumstance).

The local protocol approved by the DTC must assure: 

1. the identity of the patient is confirmed 
2. the correct medication and fluid (if relevant) is administered 
3. the dose is appropriate and the calculations are correct
4. correct dosage settings and adjustments are made to a rate limiting device such as an infusion pump 
5. countersigning of the administration on the medication chart by the RN/RM who supplied the medication against that of the administering RN/RM occurs
6. countersigning of the amount of any medication discarded by the RN/RM in the isolation room occurs.

Document information

Developed by

Judith Mackson, Chief Pharmacist and Director, Chief Pharmacist Unit, NSW Ministry of Health

Consultation

• DaTA COP
• NSW Directors of Pharmacy Network
• NSW Ministry of Health Nursing and Midwifery Office
• Clinical Excellence Commission Medication Safety

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning

For use by

Local Health Districts, Speciality Networks, Affiliated Health Organisations, NSW Health Pillars