Different medication schedules are handled differently when brought into a hospital setting. Types of medication schedules seen in a hospital setting can include schedule 2, 4, 4D and 8. Schedule 2 medications are items that can be bought over the counter without a prescription. They include some cough syrups (bromhexine, dextromethorphan, guaifenesin and pholcodine), antihistamines (cetirizine, fexofenadine and loratadine), folic acid, analgesics (ibuprofen and paracetamol), loperamide, macrogol, and some nasal sprays (xylometazoline). Schedule 3 medications are items kept inside the pharmacy out of patient reach and do not require a prescription. These items include clotrimazole in preparations for vaginal use, diclofenac 25mg tablets in a 20 pack, hydrocortisone 1% cream, and salbutamol inhalers. Schedule 4 medications require a prescription to be supplied and can include antibiotics (cephalexin, amoxicillin and metronidazole), analgesics (meloxicam, diclofenac 50mg, celecoxib), thyroxine, and domperidone. Restricted schedule 4 medications (alternatively referred to as S4D, S4R or S11 medicines) are schedule 4 medicines that are liable to abuse such as benzodiazepines (diazepam and temazepam), codeine-containing medications and tramadol. Medicines included in this category may vary slightly in accordance with each hospital policy, but they should be stored in a safe with a separate drug register kept. Schedule 8 medications include drugs of addiction that need to be locked away in a separate safe with a register of drugs kept. Schedule 8 medications include medications such as all forms of oxycodone, fentanyl and dexamphetamine. Some medications may appear in more than one schedule depending upon factors such as strength, quantity, and the presence of other therapeutically active agents in the formulation. The Poisons Standard can be consulted for further information.
Patients who come into hospital with their own regular medications should be told that their medications need to be stored correctly. Any schedule 2, 3 or 4 medications can be stored in the patient’s bedside drawer. Other restricted schedule 4 and schedule 8 medications will need to be taken off the patient, stored in the treatment room safe and added to the nurse’s register so that an accurate balance is always kept.
Storage in a hospital ward
Rules for the storage of restricted schedule 4 and schedule 8 medications vary slightly according to state and territory law. For example, in NSW, the Poisons and Therapeutic Goods Regulation 2008 Part 4 > Division 2 > Clause 75 states that drugs considered drugs of addiction must be stored in a securely locked safe separate from other medications. The pin or key to unlock the safe must only be known or carried by a registered nurse or midwife.
Record of supply on the wards
Drug registers need to be kept for all schedule 8 medications. The requirements for restricted schedule 4 medications may vary according to state and territory law and individual hospital policies. For drugs that require use of a drug register, the following points should be followed:
- The register’s pages must be consecutively numbered;
- The register must be a bound book where pages cannot be removed or replaced;
- Each drug of addiction must be recorded on a separate page of the register; and
- Each drug needs to be written down with the correct name, formulation of the drug, and the strength of the drug.
Entry into the register must be completed whenever a drug of addiction is received, supplied or administered. The ward register must record:
- The quantity received, supplied or administered;
- The date and time the drug was received, supplied or administered;
- Name of the patient and registered nurse’s name and signature. Each entry must also be countersigned; and
- The quantity left once the drug has been received, supplied, or administered.
The drugs of addiction kept in the safe and recorded in the register must be counted, and quantities checked and countersigned each day usually at the beginning and end of a nurse’s shift.
Destruction of drugs of addiction in the hospital
It is recommended that destruction of unwanted drugs of addiction in a private health facility occurs frequently. NSW regulations advise that this should occur once a month with a registered pharmacist practising at that facility and the hospital’s director of nursing. On these rounds, drugs of addiction that are expired, left by previous patients, or faulty are destroyed and signed out of the registers. The pharmacist must record the medication being destroyed, the amount being destroyed, the date and time of destruction, the pharmacist’s Australian Health Practitioner Regulation Agency (AHPRA) registration number with full name and signature alongside the name and signature of the witness.