Recommendations from Report on the supply and management of Schedule 8 controlled drugs at certain public hospitals in Western Australia tabled on 20 June 2017.

After-hours access to pharmacy and safe

  • Enhance monitoring of after-hours access to the pharmacy and the pharmacy safe.
  • Give consideration to:
    • mandatory audits for all after-hours supply or dispensation from the pharmacy safe;
    • prohibiting after-hours solitary access to the pharmacy safe; and
    • increasing security and monitoring through technology.

Reconcile supply and receipt

  • Develop and implement a practice to reconcile drugs supplied by a public hospital's pharmacy with receipt by wards and units.

Separation of duties

  • Implement procedures that mandate and reinforce the 'separation of duties' in relation to each act required in the supply processes.

Regular compliance checks

  • Conduct regular checks on randomly selected staff, wards and units in order to ascertain the extent of compliance with policies, procedures and practices.
  • Conduct independent audits from time to time that measure compliance with policies, procedures and practices.


  • Develop and implement practices in relation to registers that:
    • enable registers to be produced, without delay, in response to a request by an investigator or compulsory processes;
    • provide heightened security to the registers; and
    • audit the movement of registers.

Update and consolidate policies, procedures and practices

  • Update and consolidate procedures and practices to align with the current statutory regime.

Knowledge sharing

  • Implement a forum for chief pharmacists of public hospitals to share knowledge about drug diversion risks and solutions.

Modernise requisition and register system

  • Consider the introduction of an auditable electronic requisition process.
  • Consider the introduction of auditable electronic registers.

Enhance automated systems

  • Take action to maximise Schedule 8 drugs on the imprest list.
  • Take action to inhibit automated systems allowing a pharmacist to supply imprest drugs manually.

Progressively introduce automation to public hospitals

  • Progressively introduce automated electronic storage and supply unit systems to public hospitals to enhance efficiencies and security.