Bad S8 practice lands licensees in hot water


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Four pharmacy licensees have faced Panel Hearings on charges including discrepancies with S8s – with one case including pharmacotherapy drugs

The Victorian Pharmacy Authority outlined four Panel Hearing cases held late last year in which two pharmacy licensees were reprimanded and two cautioned.

The Authority also explained why some cases result in a reprimand, and others a caution.

In one case, the licensee faced charges regarding discrepancies between stocks of S8 poisons and the electronic register; unsatisfactory disposal of printed confidential information; and incorrect storage of S8s.

“Overall management of the pharmacotherapy service was deficient in that the methadone stock bottle was not clearly labelled, photographs of some patients were absent and accounting for the use of methadone and buprenorphine was unsatisfactory,” the Authority observed.

The licensee was reprimanded and a condition inserted in the licence that requires them to carry out quarterly audits, renewable at 12 months and each to be accompanied by a statutory declaration attesting to its veracity.

The Authority said the pharmacy would be re-inspected at the licensee’s cost.

Another case outlined by the Authority also featured “numerous discrepancies” in both the storage and recording of S8s. Movement detector sensors did not provide adequate coverage of the pharmacy.

In this case, the licensee had also failed to make adequate arrangements to ensure returned medicines were not re-used, and had not been storing and disposing of them in a secure manner.

At this pharmacy, records containing confidential information were not disposed of properly; refrigerator temperatures were not monitored; current works of reference were not held; barcode scanning was inadequate and there were deficiencies in the recording of medicines used in dose administration containers.

The licensee was reprimanded and this pharmacy was also set to be re-inspected at the licensee’s cost.

A third hearing concerned a pharmacy where there were also discrepancies in accounting for S8 poisons, and the keys to the S8 case were not secured.

Barcode scanning was not undertaken regularly and there was no temperature data logger in the refrigerator.

The Panel found that the dispensary and its surrounds did not prevent clients from approaching and standing directly in front of the dispensary in order to minimise interruptions and distractions to the dispensing process and to prevent the disclosure of documents and the identity of patients’ medicines.

It said the dispensing balance was to be repaired and certified or replaced and the range of dispensing measures increased. The name of the proprietor was to be displayed at all public entrances.

The licensee was cautioned.

Lastly, another licensee was cautioned after the Panel found that the control of keys to the pharmacy premises was not restricted to registered pharmacists.

In this case there were also discrepancies in the S8 register; the part of the shop where DAAs were assembled was not maintained in a hygienic manner; and there was inadequate security of perimeter doors.

Temperature control, signs and equipping were also found to be unsatisfactory.

In a communique the Authority took the step of outlining why some licensees are reprimanded and others cautioned.

“The extent and range of matters that form the charges and past history are factors that affect the finding,” it said.

“During the hearing, the Panel notes what steps the licensee has already taken to rectify the deficiencies listed in the inspection report.

“Section 61 of the Pharmacy Regulation Act 2010 states: ‘If it considers appropriate to do so, the Authority may caution or reprimand a licensee or holder of registration instead of revoking the licence or registration’.”

It also outlined a series of lessons other pharmacists can learn from the four panel hearings:

  • The Act prohibits the re-use of medicines after dispensing and after they have left a pharmacy or pharmacy department. Dispensed medicines that have left the premises cannot be re-used.
  • The Act requires the control of keys or other entry devices (to a pharmacy or pharmacy department) to be restricted to registered pharmacists. Keys cannot be given to any other person, including the police.
  • Pharmacy dispensaries must be set up in a way that prevent s clients from approaching and standing directly in front of the dispensary to avoid distractions and breaches of privacy.
  • The Authority continues to convene Panel Hearings to hear allegations into failures of good pharmacy practice relating to the storage and recording of Schedule 8 poisons.

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