Training guide
Reporting S8 and S4R medicine discrepancies in public hospitals
Overview

This Guide will set out the process for managing and reporting medicine
discrepancies in WA public hospitals (including private patients treated in
public hospitals) and private facilities treating public patients.

It is based on: Operational Directive 0377/12 Reporting of medicine
discrepancies in public hospitals and licensed private facilities which
provide services to public patients in Western Australia

OD 0377/12 supersedes OD 0140/08 Reporting of Schedule 8 Medicine
Stock Discrepancies in WA Public Hospitals and OD 0169/09 Reporting
Medicine Losses in WA Public Hospitals.

The following documents are associated with the Operational Directive:
 Medicine Discrepancy and Loss (MD/L) Report form
 Flow-chart: Managing and reporting medicine loss in public hospitals

Relevant legislation/directives:
 Poisons Act 1964, Poisons Regulations 1965
 Operational Directive OD 0215/09 Storage and Recording of Restricted
Schedule 4 Medicines.
Return to contents page
Return to last slide viewed
Table of contents
Overview
What’s new?
What is a medicine discrepancy?
Roles and responsibilities – hospital staff
Roles and responsibilities – others
Who is my Medication Incident Coordinator (MIC)?
Flowchart
Quick Guide: How to report a medicine discrepancy
Quick Guide: Medicine not located in 24 hours
Quick Guide: Outcomes of incident review
Quick Guide: After the incident review
Medicine discrepancy/loss report form
Using the form
Tips for completing the form
Reporting multiple incidents
Reporting after hours, long weekends and holidays
Liquids
Trend analysis
Practice reviews
What happens to reports
Misconduct
Case study: single discrepancy reporting
Case study: reporting multiple discrepancies
Case study: liquid discrepancies
Where to go for further information
What’s new?

defined roles and responsibilities:
 Notifier
 Medication Incident Coordinator
 Incident Reviewer

timeline for:
 initial follow up and reporting: 24 hours
 subsequent review if required: 72 hours

report form:
 lists the steps to take in initial follow up and subsequent review
 is an e-form: can type into fields, save form, email or print.
Return to contents page
Return to last slide viewed
What is a “medicine discrepancy”?
A medicine discrepancy is a mismatch
between the stock on hand and the register
balance. It can be an excess or a loss.
This Operational Directive only applies to
Schedule 8 and restricted Schedule 4
medicine discrepancies.
Return to contents page
Return to last slide viewed
Roles and responsibilities – hospital
Notifier
The person who identifies a medicine discrepancy, undertakes initial follow up and reports
discrepancies to the MIC and Corporate Governance Directorate within 24 hours.
Medication Incident Coordinator (MIC)
A senior staff member who is responsible for receiving medicine discrepancy reports and
nominating Incident Reviewers.
A MIC may:
 be based at one central site and have responsibility for multiple locations (e.g. a
tertiary hospital plus annexes, or a WACHS region).
 have responsibility for a nominated area within a site (e.g. a specific ward or a group of
wards).
The MIC retains reports, undertakes trend analysis, practice reviews and implements
change to improve prevention and management of medicine discrepancies.
Incident Reviewer
Nominated by the MIC for each incident where initial follow up has not explained the
discrepancy.
The Incident Reviewer:
 undertakes additional review
 submits reports to Corporate Governance Directorate and the MIC
Hospital
The Executive Director of each site must designate the MIC/s and must advise Corporate
Governance Directorate of the position/s nominated and the contact details for the
occupants of the positions.
Return to contents page
Return to last slide viewed
Roles and responsibilities – others
Corporate Governance Directorate




receives and reviews Medicine Discrepancy and Loss report forms
enters reports into a database and conducts trend analysis of report data for misconduct
risk management purposes
assesses and manages misconduct reports and investigations
reports unexplained and misconduct related medicine losses to the Corruption and Crime
Commission.
Pharmaceutical Services Branch


reviews all reports of Medicine Discrepancy and Loss
investigates breaches of the Poisons Act 1964 and Poisons Regulations 1965.
Corruption and Crime Commission



receives reports of misconduct related and unexplained medicine loss from Corporate
Governance Directorate
assesses and investigates allegations of misconduct by public officers
reviews misconduct management systems to work towards the prevention of misconduct.
Police


receives reports of theft and poison loss
investigates breaches of the Misuse of Drugs Act and Criminal Code.
Return to contents page
Return to last slide viewed
Who is my Medication Incident Coordinator
(MIC)?

The MIC will be a senior staff member who is responsible for receiving
medicine discrepancy reports and nominating Incident Reviewers.

A hospital may have more than one MIC.

Your MIC might be:
 the Director of Pharmacy or a senior pharmacist at your site
 the Director of Nursing or the Nurse Director for your area
 a medical practitioner or Unit director.

Check the flowchart on Investigating and reporting medicine loss in public
hospitals – there is space for the MICs name to be recorded here.
Return to contents page
Return to last slide viewed
Flowchart

The flowchart has been designed to:
 outline the steps involved in
identifying and reporting medicine
discrepancies
 show the staff members involved in
the process.

It is recommended that the flowchart be
printed and displayed in a prominent
place to assist staff when a medicine
discrepancy is identified.

The name of the Medication Incident
Coordinator for the area can be noted on
the chart to assist with reporting.

The flowchart can be downloaded via the
Department of Health Operational
Directives and Circulars webpage
Return to contents page
Return to last slide viewed
Quick guide: How to report a medicine discrepancy
If you notice a medicine discrepancy you must, within 24 hours:
1.Tell people – get your pharmacist, SRN/M and security officer on
board. They may assist with follow up if needed.
2.Follow up the discrepancy. The Medicine Discrepancy/Loss report form
has a checklist to guide you.
If you locate the medicine or find that there was no discrepancy:
 you do not have to submit a report.
 update the register balance (if required).
 advise notified staff of the outcome of the follow up.
 check your hospital policy to see if you need to do anything else.
Return to contents page
Return to last slide viewed
Quick
Quick
guide
guide
continued
continued:
Discrepancy identified  follow up checklist 
medicine not located
+2
4hr
s
+7
2hr
s
The Notifier (person who notices the discrepancy) must:
 correct the register balance.
Example text: DD check – discrepancy between balance and stock on hand
 complete Section 1 of the Medicine Discrepancy and Loss Report form
 send the report form to the Medication Incident Coordinator and Corporate
Governance Directorate within 24 hours of the incident being identified.
The Medication Incident Coordinator must:
 nominate an Incident Reviewer
 forward the Incident Reviewer the report form.
The Incident Reviewer must:
 confirm the initial findings
 conduct a review of the incident. The Medicine Discrepancy and Loss Report
form lists the steps that should be followed.
Return to contents page
Return to last slide viewed
Quick
Quick
guide
guide
continued
continued:
Outcomes of the incident review
Outcome of review
Explanation
No loss/medicine located
Where the review identifies that there was no actual
medicine loss. Example: where medication was
administered but not recorded.
Unexplained loss
Where the review does not identify a cause for the
discrepancy and the medicine has not been located.
Explained loss: system/practice related
Where the cause of the loss is identified (not
misconduct) but the medicine has not been located.
Explained loss: misconduct related
Where the medicine has not been located and the
cause of the loss can be attributed to, or can be
reasonably suspected of being attributed to,
misconduct.
Return to contents page
Return to last slide viewed
Quick
Quick
guide
guide
continued
continued:
After the incident review
+72
hrs
The Incident Reviewer must:
 report theft and losses to the Police by phoning 131 444
 report suspected misconduct to site Human Resources and Corporate
Governance Directorate
 advise pharmacy, nursing and security staff of the outcome of the review
 complete Section 2 of the Medicine Discrepancy/Loss Report form
 forward the report form to the Medication Incident Coordinator within 72
hours of the discrepancy being identified.
The Medication Incident Coordinator must:
 liaise with site Human Resources and Corporate Governance Directorate
regarding any misconduct report submitted
 complete Section 2 of the Medicine Discrepancy/Loss Report form
 forward the report to Corporate Governance Directorate within 72 hours of
the discrepancy being identified.
Return to contents page
Return to last slide viewed
Medicine Discrepancy & Loss (MD/L)
Report form

The form has been designed to:
 guide staff in the follow-up and review of medicine
discrepancies
 collect data to assess and manage medicine
discrepancies.

The form is broken into two sections:
 Section 1: to be completed by the person identifying
the discrepancy, the Notifier, within 24 hours of the
discrepancy being identified.
 Section 2: to be completed by the Medication Incident
Coordinator and the Incident Reviewer within 72 hours
of the discrepancy being identified.

Forms can be downloaded via the Department of Health
Operational Directives and Circulars webpage.
Return to contents page
Return to last slide viewed
Using the report form
Print the form to fill in by hand or you can complete the form online.
When you fill in the e-form you can:
 type directly into fields and can “Save As” for later
 include more detail - fields will expand if required
 add rows to report multiple incidents on one form and delete rows if required
 print or email the completed form.
When you email the form:
 you insert your HE number in the signature field
 the fields you have completed will be locked against update
 you can notify Pharmacy, senior Nursing and Security staff of the incident by
including them in the email
 scanned copies of relevant documents (e.g. registers or rosters) can be sent with
the report form.
Return to contents page
Return to last slide viewed
Tips for completing a report

If anyone else assisted in the process, include their names in the details
section.

Talking with staff:



Outcome details:




Include the names of staff spoken to and any staff who were unavailable
Document staff recollections about the incident and record any relevant activity
that occurred at the time the incident is thought to have occurred.
Complete the details sections separately for each discrepancy identified. Make
sure the report number is the same as in the Incident Details section of the form
If something can’t be completed within 72 hours, note this down on the form and
then submit a supplementary report once it’s complete
Always report to Police where required under the Poisons Regulations 1965 and
this Operational Directive. If the Police refuse to accept a report (this sometimes
happens with unexplained losses) make a note in the Police Report Notes
section of the report form and Corporate Governance will follow this up directly
with Police.
Close the communication loop by notifying nursing, pharmacy and security
staff of the outcome of review. If you are emailing the report form you can
notify staff by including them on the email recipient list.
Return to contents page
Return to last slide viewed
Reporting multiple incidents
You can use the e-form to submit multiple incident reports on the one form.
Only incidents from the same location, of the same type and identified at the
same time should be reported on the one form.
Time
the discrepancy was
identified
Discrepancy type
Location
One form
Multiple forms
Same time
Different times
(e.g. during the same register balance check)
(balance checks done on different days)
Same type
Different types
(e.g. loss or excess, imprest or dispensed)
(e.g. hospital imprest stock and patient’s own
medicine)
Same location
Different locations
(e.g. same ward)
(e.g. different wards)
Return to contents page
Return to last slide viewed
After hours, long weekends and holidays
+2
4hr
s
+7
2hr
s

When a medicine discrepancy is noticed, the initial follow up and
reporting must be completed within 24 hours.

This may mean completing the follow up process before the end of
your shift if you are not rostered on again the following day.

Talk with your SRN/M and pharmacist – they may be able to assist in
the follow up process.

When subsequent review is required this should be completed within
72 hours of when the incident was first noticed.

If the incident is reported to the Medication Incident Coordinator after
hours or at the start of a long weekend, the review process may not
be fully complete within the 72 hour time period. If this happens, a
report should still be submitted within 72 hours – just note in the
report which tasks have been completed and which are still to be
done. Submit an update once the review is complete.

If staff are unavailable for interview or are on leave during the review
process, note this is the report and submit an update once they have
been interviewed.
Return to contents page
Return to last slide viewed
Liquids

It is recognised that there are particular issues relating to
balance discrepancies in liquids.
 All liquid discrepancies must be
reported. There is no acceptable
level of liquid loss.

To reduce the risk of balance discrepancies:
 Use only one bottle at a time.
 In addition to routine stock checks, liquids should also
be reconciled at the end of each bottle using a
syringe.
 Use oral dispensing syringes and a bung in the bottle.
 Pharmacies to ensure the supply of the smallest
commercially available quantity of S8 medicines to
wards. Pharmacies should not repackage liquids into
smaller bottles.

Relevant document:
Guidance note: Measurement of S8 oral liquids
(can be downloaded online under Policies and Guidelines)
Return to contents page
Return to last slide viewed
Trend analysis

Performed by: the Medication Incident Coordinator

Looking for: repeating WHO, WHAT, WHEN, WHERE

Purpose: to identify a common cause of, or contributor to, medicine
discrepancies that occurs across multiple incidents.
When trends are identified that contribute to medicine discrepancies changes
should be implemented to address the risk.
Example: Multiple reports of a particular medicine going missing from ICU
Resuscitation trolleys which, once identified as a trend, may lead to the
removal of those medicines from the trolleys.
Summary information of reports submitted from your site may be requested
from the Corporate Governance Directorate to assist Medication Incident
Coordinators when undertaking trend analysis.
Return to contents page
Return to last slide viewed
Practice reviews

Performed by: the Medication Incident Coordinator

Looking for: deviations from standard practice or areas where standard
practice is deficient in preventing medicine discrepancies from occurring.

Purpose: to identify areas for change and provide evidence for practice
change where required.
Changes may include:
 policy/process review
 performance management
 in-service or staff training
 identifying and implementing the use of tools to assist best practice.
Example: Reports of stock imbalance in liquids may be reduced by the routine use of
oral dosing syringes.
Return to contents page
Return to last slide viewed
What happens to reports?
Discrepancy identified
Follow up checklist
Incident
Medicine not located
reviewer
Pharmaceutical
Services Branch
Notifier
Section 1- MD/L Report form
Medication Incident
Coordinator
Corporate
Governance
Directorate
Corruption and
Crime
Commission
Once reports reach Corporate Governance Directorate:

Each individual report is assessed to determine if additional investigation is
required. Reviewers are looking for misconduct or breaches of the Poisons
Act 1964 or Poisons Regulations 1965.

All reports of unexplained medicine loss and misconduct related loss are
forwarded to the Corruption and Crime Commission (CCC).
The CCC may require additional information to be obtained or investigation
conducted.
Return to contents page
Return to last slide viewed
Misconduct

Misconduct should be reported to Corporate Governance Directorate as
soon as possible.

Reporting of misconduct cannot be delayed while internal investigations are
carried out.

Corporate Governance Directorate is available to conduct training on
misconduct identification and reporting.

Relevant documents:
 Operational Directive OD 0323/11 WA Health Misconduct and Discipline
Policy
 Misconduct and discipline guidelines: metropolitan health service and
WA country health service staff.
Return to contents page
Return to last slide viewed
Case studies
 Single medicine discrepancy:
Betty Browne notices there is a hydromorphone tablet missing from the S8
locked cupboard in Emergency.
 Multiple medicine discrepancies:
June Jones does a register balance check and notices a number of
discrepancies in Ward 1.
 Liquid medicine discrepancy:
Jacob Ladder notices that the Ordine® liquid has run out early.
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section
Incident details
Incident 1:
details
Medicine Discrepancy/Loss Report form
Section 1 is
completed by
the person who
notices the
discrepancy
(the Notifier).
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section 1: Actions - Notify staff and follow up checklist
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section 1: Outcome, sign off, submission
Outcome:
document the
outcome of the
follow up
process.
Was the
medicine
located? Has
the register
balance been
corrected? Have
any issues been
identified?
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section 2: Incident details
Section 2 is
completed by
the Medication
Incident
Coordinator
and the
Incident
Reviewer.
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section 2: Incident review checklist
Return to contents page
Return to last slide viewed
Single medicine discrepancy
Section 2: Outcome, notification and sign off
If WA Police will not accept a
report (this sometimes
happens for unexplained
losses), make note on the
report form and Corporate
Governance Directorate will
follow up directly with Police.
Printed form:
Notifier to sign
by hand
Emailed form:
ok to use HE
number in sign
off section.
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 1: Incident details
Using the report form for multiple medicine discrepancies
Section 1 is
completed by the
person who
notices the
discrepancy (the
Notifier).
Report Number:
automatically
generated within
the report form.
Outcomes must
match the correct
report number.
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 1: Actions – Notify staff and follow up checklist
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 1: Outcome
Complete this
section separately
for each medicine
discrepancy
identified.
Make sure that the
Report Number is
the same as in the
Incident Details
section.
Outcome:
document the
outcome of the
follow up
process.
Was the
medicine
located? Has
the register
balance been
corrected? Have
any issues been
identified?
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Incident details
Section 2 is
completed by
the Medication
Incident
Coordinator
and the
Incident
Reviewer.
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Incident review
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Incident review continued
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Outcome
Complete this
section
separately for
each medicine
discrepancy
identified.
Make sure that
the Report
Number is the
same as in the
Incident Details
section.
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Outcome continued
Return to contents page
Return to last slide viewed
Multiple discrepancy report
Section 2: Outcome continued
Printed form:
Notifier to sign
by hand
Emailed form:
ok to use HE
number in sign
off section.
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 1: Incident details
Reporting a liquid loss
Section 1 is
completed by
the person who
notices the
discrepancy
(the Notifier).
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 1: Actions – Notify staff and follow up checklist
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 1:Outcome, sign off and submission
Outcome:
document the
outcome of the
follow up
process.
Was the
medicine
located? Has
the register
balance been
corrected? Have
any issues been
identified?
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 2: Incident details
Section 2 is
completed by
the Medication
Incident
Coordinator
and the
Incident
Reviewer.
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 2: Incident review checklist
Return to contents page
Return to last slide viewed
Liquid discrepancy
Section 2: Outcome, notification and sign off
Printed form:
Notifier to sign
by hand
Emailed form:
ok to use HE
number in sign
off section.
Return to contents page
Return to last slide viewed
Further information and assistance:
 Medication Incident Coordinator for your area
 Pharmaceutical Services Branch
(8.30am to 4.30pm Monday to Friday)
Phone: 9222 6883
 Corporate Governance Directorate (24/7)
Phone: 1800 000 224
 Human Resources for your site
Return to contents page
Return to last slide viewed