S8 use, incident reports on the rise

For safe dispensing, it’s important to be aware of the four key factors in S8 dispensing incidents, says indemnity body

Most pharmacists will be aware of the ever-expanding range of Schedule 8 products and the increasing number of prescriptions being written for these medicines, says PDL, which has also noted a rise in the number of reports involving this group of medicines.

“This is of concern to PDL because of the potential risk for significant consequences for patients, pharmacists and others,” says the group.

“This group of medicines is being prescribed in increasing numbers and greater vigilance is vital when supplying these items.”

Familiarity, Frequency, Complacency, Criminality are all factors in S8 dispensing incidents, says PDL.

“Don’t let familiarity, frequency or complacency be a factor in an incident.”

Review of incident reports involving S8 medicines have identified several factors and potential causes of these incidents. These include:

Incorrectly translated dosing: Methadone prescribing typically indicates the dose in milligrams however errors occur when this dose is incorrectly translated to mL thereby providing a dose five times greater than intended

Confusion over packaging: Suboxone errors can occur as prescribed doses often involve a combination of 2mg and 8mg films. Confusion due to similarity of packaging, multiples of films required and supply of the incorrect strength of film e.g. 8mg film instead of a 2mg film or vice versa can lead to under or over dosing

Omission of barcode scanning: Omission of barcode scanning following dispensing of S8s is a factor in a significant number of incidents reported to PDL. It appears this omission of scanning occurs at a higher frequency in these items than in non-S8 items.

It is possible that the reduced rate of scanning may be associated with the break in the normal dispensing process due to collection of the S8 from its storage location. High-risk medicines such as the S8s warrant great vigilance and should always be scanned as part of the checking process.

Input error: This is a significant cause of dispensing errors across all medicine types and S8s are no different in this regard. With a large number of variations of strength and form, attention must be maintained when entering these items into the dispensing program.

Consistent use of prescription barcodes as a means to input details can minimise the risk of input error though it is acknowledged that this system is not 100% accurate

Following on from this point, the large range of products within a brand or molecule is also a consideration. This includes multiple strengths within a range such as Targin or Oxycontin as well as various forms including immediate release products and controlled release versions. Common examples of this error include Palexia IR versus Palexia SR, Ritalin versus Ritalin LA, oxycodone tablets/capsule versus modified release oxycodone etc.

Supply of a quantity other than that prescribed: Typical examples include oxycodone tablet/capsule in a quantity less than a standard pack e.g. 10 however a standard pack is supplied. A similar circumstance occurs with Oxycontin/Targin prescribed as 20 but a standard pack of 28 is provided. It is often difficult to confirm the patient has received more than intended as well as difficult to retrieve the excess medicines

Forgery of S8 prescriptions: This is an increasingly frequent problem faced by pharmacists. Awareness, logic and good procedures may help to prevent being caught in such a situation. Factors often seen in the supply of S8s on a forged prescription include after-hours presentation, inability to contact the prescriber, faxed or emailed prescriptions which are confirmed by a “prescriber” calling the pharmacy to increase perception of validity, excessive quantities and the common indication that the prescription is non-PBS. This final point is particularly common with fentanyl prescriptions including those for quantities exceeding a standard pack.

Case Study

A patient with multiple health conditions including chronic pain was stabilised on Targin 5/2.5 twice daily. The patient presented a new prescription for Targin 5/2.5, quantity 56 tablets. The pharmacy only had 28 tablets in stock. These were supplied and the patient was asked to collect the remaining tablets in two days’ time.

Once the stock was delivered a box of Targin was labelled and given to the patient.  Unfortunately the second box of Targin was 40/20mg but this error wasn’t detected until later that day when the stock count didn’t balance. It was determined that the second box was not scanned because the dispensing program would not allow for this to occur after the transaction had been finalised on the cash register.

The pharmacist contacted the patient who denied they had received the higher strength item. The patient refused to return to the pharmacy with the second box and hung up on the pharmacist. Further attempts by the pharmacist to call the patient were unsuccessful as the patient would not take their call. The pharmacist was concerned there was a risk for the patient or others if this medicine was not retrieved.


pdl logoAs the pharmacist was not comfortable going to the patient’s address they called the police, explained the situation and requested a welfare check. As this was in a rural town, the police were able to attend to the patient’s address and following some discussion the patient provided the police with an intact box of Targin 40/20 which was returned to the pharmacy. The correct item was dispensed and given to the patient at their next visit to the pharmacy.

PDL is a pharmacy member organisation that provides support for pharmacists and the profession, as well as Pharmacist Professional Liabilities Insurance (PI) cover. 

For 24/7 incident support for pharmacists, phone 1300 854 838.

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1 Comment

  1. Stephen Schwarz

    Why have doctors not been forced to update their computer systems to automatically include the prescription barcode, and this to be printed correctly so our reader can read it. I know this is not 100% foolproof, but would go a long way to minimise errors.

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