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.
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:
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.
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:
The local protocol approved by the DTC must assure:
Judith Mackson, Chief Pharmacist and Director, Chief Pharmacist Unit, NSW Ministry of Health
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
Local Health Districts, Speciality Networks, Affiliated Health Organisations, NSW Health Pillars