Medication Management and Scheduled Medicines Policy

Purpose. This policy sets the rules for prescribing, dispensing, storing, administering and disposing of medicines and vaccines across Lakeside Health, including the handling of scheduled and controlled medicines.

1.Purpose and scope

Medicines are the most common cause of preventable harm in primary care. This policy applies to the pharmacy, the treatment rooms, the dental clinic, the emergency trolley, vaccine fridges and any medicine held on any site.

2.Prescribing and administering

Medicines must be prescribed only by practitioners authorised to do so and administered only by staff within their scope of practice, under a valid order, after checking the patient's identity, allergies and the medicine, dose, route and time. Every administration must be recorded in the patient record with the batch number for vaccines.

3.Storage and security

Scheduled medicines must be stored in the pharmacy and treatment rooms in locked cupboards accessible only to authorised staff. Controlled medicines must be kept in the drug safe with a register that records every receipt, administration and balance check, signed by two authorised staff. Keys and codes must never be shared or left in the lock.

• Drug safe register balanced at every shift change
• Discrepancies reported to the Pharmacist in Charge immediately
• Expired controlled medicines destroyed with a witness and recorded
• Restricted access to the imprest cupboards

4.Cold chain

Vaccines must be stored in purpose-built vaccine refrigerators between 2 and 8 degrees Celsius with continuous temperature logging. The fridge temperature must be read and recorded twice a day. Any excursion outside the range must be treated as a cold chain breach: the vaccines must be isolated, not used, and the state immunisation program contacted for advice.

5.Imprest and stock

The pharmacy will supply imprest stock to the treatment rooms and the dental clinic against an agreed list, check the imprest weekly and remove expired or damaged items. Emergency drugs on the trolley must be checked and recorded weekly and after every use.

6.Errors and disposal

Every medication error or near miss must be reported in the incident register and reviewed by the Pharmacist in Charge and the treating practitioner. Unwanted and expired medicines must be placed in the returned medicines container and never in general waste or the sewer.

7.Review

This policy will be reviewed every year and after any serious medication incident. The Pharmacist in Charge will report imprest, cold chain and error data to the clinical governance committee monthly.