Key requirements for nurses in residential aged care services
- This summary has been prepared by the Drugs and Poisons Regulation Group (DPRG) to assist nurses in understanding their obligations under the Drugs Poisons and Controlled Substances Act 1981 and Regulations 2006. Reference must be made to the legislation (at www.legislation.vic.gov.au) for full details.
For easier reading and comprehension, this summary does not include the many and varied options that are covered by the legislation. Instead, it focuses on the circumstances that are applicable to the majority of nurses in residential aged care services; for example, references to Schedule 9 poisons are not included.
Schedule 8 poisons (labelled Controlled Drug) are drugs with more strict legislative controls, e.g. cocaine, morphine, pethidine, oxycodone, methadone, hydromorphone, flunitrazepam, fentanyl, ketamine.
Schedule 4 poisons (labelled Prescription Only Medicine) include other drugs for which prescriptions are required, e.g. cardiovascular drugs, antibiotics, nitrous oxide & many others.
The term “drugs of dependence” is used to describe substances listed in Schedule 11 to the Act and includes all S8 poisons plus those S2, S3 or S4 poisons known to be subject to misuse and trafficking, e.g. pseudoephedrine, benzodiazepines, dextropropoxyphene, midazolam.
Note: Most regulations relate primarily to whether a drug is in Schedule 4 or Schedule 8 (not Schedule 11) so, to avoid confusion, it is recommended that Diazepam and similar substances be referred to as Schedule 4 drugs of dependence – rather than as Schedule 11 drugs.Registered Nurse means a nurse registered by the Nursing and Midwifery Board of Australia as a ‘Registered Nurse’ in the national register of nurses (and equivalent to those previously registered in Division 1, 3 or 4 of the Nurses Board of Victoria register).
Enrolled Nurse means a nurse registered by the Nursing and Midwifery Board of Australia as an ‘Enrolled Nurse’ in the national register of nurses (and equivalent to those previously registered in Division 2 of the Nurses Board of Victoria register).Note: In the Drugs Poisons and Controlled Substances Regulations 2006, the term “nurse” is defined to include registered nurses and enrolled nurses - other than enrolled nurses who do not hold a Nursing and Midwifery Board of Australia approved qualification in medicines administration.
Accordingly any person, who has the care of (or is assisting in the care of) a resident for whom a medicine has been supplied on prescription, could be authorised to possess that medicine for the specific purpose for which it was supplied. In a residential aged care service, such a person may be a nurse or a personal care attendant (PCA).From 1 July 2010, Section 136 of the Schedule to the Health Practitioner Regulation National Law (Victoria) Act 2009 replaced a similar provision in Section 85 of the Health Professions Registration Act 2005. Section 136 of the Schedule states that ‘A person must not direct or incite a registered health practitioner to do anything, in the course of the practitioner’s practice of the health profession, that amounts to unprofessional conduct or professional misconduct.’
ManagementWhere a resident in an aged care service is receiving high-level residential care, the Act specifies that the administration of Schedule 4 or Schedule 8 poisons, to that resident, must be managed by a Registered Nurse (see Key terms for definition) in accordance with the relevant code for guidance (if any) issued by the Nursing and Midwifery Board of Australia.
The Nursing and Midfery Board of Australia has not yet indicated whether it intends to develop any guidance material in this area. The Code issued by the Nurses Board of Victoria was repealed with effect from 31 May 2010.Compliance with the legal requirement to ensure each high care resident’s medication is managed by a Registered Nurse may occur in a variety of ways. Compliance with this document will demonstrate compliance with the Act. An Enrolled Nurse cannot manage the administration of medication to high care residents.
The Registered Nurse with overall responsibility for management of medication must be readily identifiable to service staff and able to be contacted by DPRG. It is expected that the position will be formalised in the service’s organisational framework and role description and that staff are aware of that Registered Nurse’s role.The Registered Nurse must be free from coercion and have the necessary resources to carry out the management of the medication in accordance with his/her professional judgement and applicable professional nursing standards, for example in regard to delegation and supervision.
DelegationThe Registered Nurse who is managing the administration of medication to residents could delegate the routine supervision of other workers to whom they have delegated the task of administering medicines. This is a judgement for the Registered Nurse that must be exercised in accordance with professional nursing codes or guidelines for supervision and delegation.
As in all other aspects of nursing professional activity, a nurse is accountable for his/her professional decisions and actions. A nurse must demonstrate that delegation decisions have been properly made in accordance with professional practice guidelines and that appropriate supervision and monitoring arrangements have been put in place and followed. The worker to whom a task is delegated is also held accountable to the extent of his/her training and for following the systems and procedures required.A Registered Nurse may only delegate the administration of medicines to someone appropriately qualified to administer medicines. This means that Registered Nurses may use their professional judgement about whether to administer medicines themselves or whether to delegate the administration to someone with appropriate qualifications or scope of practice to administer medicines by the specified route.
Enrolled Nurses (who do not hold a Nursing and Midwifery Board of Australia approved qualification in medicines administration) and personal care workers (with appropriate medicines administration training) may, in some circumstances, be competent to administer medicines under the delegation of a Registered Nurse. If a Registered Nurse judges that an Enrolled Nurse or personal care worker is not appropriately qualified to administer to a ‘high care’ resident they should administer the medicines themselves or delegate to appropriately qualified personnel. Appropriate supervision must be provided.
Other residentsIt is anticipated that a resident not requiring high-level care is more likely to be personally involved in the management and administration of his/her own medications, with assistance as required.
The following requirements are applicable to an aged care service where a resident receiving high-level residential care has been supplied, on prescription, with Schedule 4 or Schedule 8 poisons.
Schedule 8 poisons must be stored in a lockable room and/or in a lockable storage facility, which is firmly fixed to a floor or wall. A steel drug cabinet is no longer mandated, due to the increased prevalence of dose administration containers, however:
- it is strongly recommended for the storage of Schedule 8 poisons in original containers;
- it is strongly recommended for the storage of Schedule 8 poisons that cannot be packed into dose administration containers;
- it is required for the storage of Schedule 8 imprest drugs - where a Health Services Permit is held;
- it may be required (e.g. for larger quantities of Schedule 8 poisons), if directed by the Drugs and Poisons Regulation Group.
Records of transactionsRecords of all administrations of Schedule 4 and Schedule 8 poisons must be true and accurate, retained in a readily retrievable form for 3 years and produced, on demand, in writing to an authorised officer of DPRG. (See regulation 40 for details that must be recorded)
For Schedule 8 poisons a separate record (e.g. a drug register or administration book that shows the true and accurate balance remaining after each transaction) is required (regulation 41) – except where a Schedule 8 poison has been supplied on prescription for a specific person in tamper-evident compartments of a suitably labelled dose administration container.
- Written instruction of a medical practitioner (the most common option).
- Oral instructions of a medical practitioner if, in the opinion of the medical practitioner, an emergency exists (e.g. telephone orders).
- Written transcription (of the emergency instructions) by the nurse who received them.
- Directions for use on a container supplied by a medical practitioner or pharmacist (e.g. administration of a person’s own lawfully supplied medication).
Nurse-initiated medicationsSome residential aged care services have protocols, which detail when a nurse may initiate treatment with specified medications other than Schedule 4 or Schedule 8 poisons. This is a matter of liability and policy – rather than of drugs and poisons legislation.
Destruction of Schedule 8 poisonsRegulation 51 authorises a nurse to act as the witness when a Schedule 8 poison is to be destroyed by a medical practitioner, nurse practitioner, pharmacist or dentist. Note: This does not mean that two nurses may destroy Schedule 8 poisons.
To clarify the situation relating to an accepted and necessary practice, this regulation specifically authorises a nurse to destroy (e.g. discard) the remaining, unused contents of a previously sterile container (e.g. a partially used ampoule) – provided the nurse makes an appropriate record. Note: As a suitably qualified person might not be available, a witness is not mandated. However many establishments have a policy that requires a witness if/when another nurse is available.
Health Services Permit (HSP) to obtain ‘imprest drugs’Some residential aged care services choose to obtain a HSP, for which an annual fee must be paid, to enable them to obtain medications that have not been prescribed for specific patients, so that selected medications are readily available for immediate administration.
Each HSP contains conditions that are specific to the type of health service provided and refers to a Poisons Control Plan, which details how the medications will be managed. All relevant application forms, details of fees, Poisons Control Plans plus instructions for how to complete them, see Health Services Permit.The following issues relate only to matters associated with the management of imprest stock.
Basic issuesMost medications in residential aged care services are supplied on prescriptions for specific patients but if a facility holds a current Health Services Permit (HSP), Schedule 4 and Schedule 8 poisons may be supplied (without prescription) so that the medications are available for urgent administration, to any patient, in accordance with instructions of a medical practitioner. Such medications, for the purpose of this document, are referred to as Imprest Drugs.
A pharmacist is considered to have supplied Imprest Drugs when possession, control of or access to the drugs is transferred to nurses at the aged care service. When/if a payment might occur is irrelevant to the question of when supply is said to have occurred.
What should occur?The permit holder (i.e. the aged care service) should provide the pharmacy with a copy of their HSP – to demonstrate that the service holds a current permit and to identify the poison schedules of the medications that may be obtained.
- When an imprest drug is ordered, the pharmacist may supply the drug in accordance with regulation 15(1)(f) and must make a record of the transaction. Imprest drugs are not supplied on prescription, so the pharmacist need not attach additional labels to the original containers.
- The permit holder should store imprest drugs separately from medications supplied on prescriptions and should manage them as described in the approved Poisons Control Plan for the HSP.
- When a nurse has a medical practitioner’s written or verbal instructions, to administer an imprest drug to a patient, the nurse may remove the required dose(s) of medication from the imprest store and must make a record of the transaction.
- If/when the medical practitioner provides a prescription, authorising the pharmacist to supply the medication for the patient, the pharmacist must supply the quantity specified on the prescription, must label the corresponding container in the manner described in regulation 29 and must make a record of the transaction. It is not acceptable to attach a dispensing label, corresponding to the subsequent prescription, to the container that was removed from the imprest store.
- The container, from which the initial dose(s) of an imprest drug were obtained, will then contain fewer doses and should be returned to the imprest store.
- Regulation 45 makes it an offence to administer drugs, obtained on prescription, to any person other than the person named on the prescription. Hence, a container of medication, obtained on prescription, must not be used to replace a container that was removed from the imprest store.
- A replacement container of an imprest drug may be supplied when the progressively reducing number of doses of the drug necessitates replenishment.