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Medicines Handling Policy

MP 139/20 - Medicines Handling Policy (pdf 317KB)

Applicable to: All Health Service Providers

Description: This Policy outlines requirements for Health Service Providers to promote accountable approaches to the handling of medicines in order to maintain the integrity of the supply chain. Whilst medicines must be available to ensure timely patient care, there is also a need to protect public health and, in particular, mitigate the risk of diversion, misuse and theft. Handling of medicines refers to the acquisition, distribution, storage, authorisation of prescribing, administration, supply, dispensing and disposal of medicines.

The Policy seeks to ensure hospitals, nursing posts and other public health service facilities operated by Health Service Providers handle medicines in a consistent manner and, where applicable, meet relevant standards. The Policy promotes a risk based approach when developing policies and procedures about the handling of medicines.

The Policy focuses on Schedule 8 (S8) medicines and a group of higher risk Schedule 4 (S4) medicines, termed Schedule 4 Restricted (S4R) medicines. The Policy also includes requirements relating to more general aspects of medicines handling, including the role of health practitioner students, health practitioner initiation of non-prescription medicines, supply of medicines to patients by staff other than pharmacists, and security of prescription stationery.

The requirements of this Policy are in addition to the legal requirements of the Medicines and Poisons Act 2014 and the Medicines and Poisons Regulations 2016 (Medicines and Poisons Legislation). This Policy recognises public health service facilities are often large organisations and the minimum requirements of the Medicines and Poisons Legislation may not be sufficient to ensure safe and accountable handling of medicines.

Individual S4 and S8 medicines may be designated as a ‘voluntary assisted dying substance’ (VAD substance), under the Voluntary Assisted Dying Act 2019 (VAD Act). Unless a VAD substance is prescribed and supplied in accordance with the VAD Act, it cannot legally be used for the purpose of voluntary assisted dying.

When a VAD substance is prescribed under the VAD Act, it becomes a ‘prescribed substance’. The possession, supply, use and disposal of a ‘prescribed substance’ is not subject to the Medicines Handling Policy and any related documents.

VAD substances supplied to a patient, including VAD substances brought into a public healthcare facility by a patient and VAD substances returned for disposal, are subject to the VAD Act and MP0154/21 Managing Voluntary Assisted Dying Policy.

The Clinical Governance, Safety and Quality Policy Framework deals with aspects of medicines management relating to clinical decisions and overall quality use of medicines (QUM).

This Policy is a mandatory requirement under the Public Health Policy Framework pursuant to section 26(2)(d) of the Health Services Act 2016.

This Policy supersedes:

OD 0142/08 Administration of Schedule 8 medicines to patients attending for emergencies
MP 0039/16 Cannabis-based Products for Medicinal Use
OD 0141/08 Code of practice for the handling of Schedule 8 medicines (drugs of addiction) in hospitals and nursing posts
OD 0598/15 Management of Community Program for Opioid Pharmacotherapy (CPOP) patients in a hospital setting
OD 0492/14 Management of Schedule 8 and Restricted Schedule 4 oral liquid medicines
OD 0529/14 Storage and recording of propofol
OD 0528/14 Storage and recording of Restricted Schedule 4 (S4R) medicines