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.

Registers

• 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.