CHAPTER 6 The administration of drugs

Every year in Australia, almost 200 million prescriptions are dispensed — that is about 10 prescriptions per year per person. In any 2-week period, 69% of the population have taken at least one medication and 91% of older people will have taken medicines.¹ It is estimated that around 140 000 hospital admissions each year are associated with problems with the use of medicines. Medication error has been estimated to result in at least 80 000 hospital admissions and costs of at least $350 million per year.² The great majority of medications that nurses administer on a day-to-day basis are considered to be, and are defined by legislation as, poisons. That is, generally speaking, they are substances that, by their very nature, are inherently dangerous to one’s health. Accordingly, it is considered necessary to identify them and then lay down clear provisions as to how such substances may be obtained, the basis on which a person may have possession of them, who may prescribe them, how they must be stored and so on. That process is undertaken by specific legislation.

The Commonwealth as well as each state and territory of Australia has specific legislation which covers the control and supply of poisons and therapeutic goods in that state or territory.³ Amongst other things, that legislation sets out the specific responsibilities of registered nurses in relation to the various types of drugs that they have to deal with and administer in their work. The possibility of drug errors, and the legal consequences that can flow from this, are such that nurses need to be aware not only of specific legislative requirements that apply to them, but also how to minimise the possibility of errors occurring.

The information contained in this chapter will be of value to both registered nurses and medication-endorsed enrolled nurses. In the past, only registered nurses were allowed to administer medications against a prescription. However, over the past five years new programs have been developed for enrolled nurses across Australia to enable what are known as ‘endorsed enrolled nurses’ to administer medications. The precise nature of the endorsement varies between jurisdictions and nurses wishing to know more should visit their respective nurse regulatory authority website for in-depth information.

The legislation referred to, known in New South Wales as the Poisons and Therapeutic Goods Act 1966, with a similar or like title in the other states and territories, does not deal only with the control of drugs in hospitals. Such legislation embraces all conceivable types of poisons available, ranging from agricultural poisons and domestic pesticides to drugs of addiction. The relevant legislation in each state and territory is relatively similar in the way in which it classifies and identifies poisons and therapeutic goods but there are differences in the detailed provisions that apply in some areas. In addition, as part of the legislation, certain criminal offences are indicated where a person deals with certain poisons, particularly the drugs of addiction, contrary to the provisions of the Act. It should be noted at this point that criminal charges in relation to well-publicised drug offences, such as possession or supply of heroin or cocaine, arise under other legislation. For example, in New South Wales such offences arise under the Drug Misuse and Trafficking Act 1985.

For the sake of clarity and because of varying legal requirements, the types of poisons or drugs available are divided into eight sections, or schedules, in a document (also called the Poisons List) which is similar in each state and territory. The various Acts do not specifically identify the drugs or poisons that come under the different schedules, but simply refer to the various poisons under broad term headings with general comment as to type. As an example, the New South Wales Poisons and Therapeutic Goods Act 1966 classifies its schedules in the following terms:

THE POISONS LIST

The Poisons List is the list of substances to which the Poisons and Therapeutic Goods Act and Regulation apply. It consists of eight schedules (Schedule 1 is empty, so reference to it has been omitted), according to a pattern which is uniform in most respects throughout Australia, as follows:

Schedule 2

Substances which are dangerous to life if misused or carelessly handled, but which should be available to the public for therapeutic use or other purposes without undue restriction. May be supplied only by medical practitioners, authorised nurse practitioners, pharmacists, dentists, veterinary surgeons or persons licensed to sell poisons.

Schedule 3

Substances which are for therapeutic use and:

(i) about which personal advice may be required by the purchaser in respect of their dosage, frequency of administration and general toxicity;

(ii) with which excessive unsupervised medication is unlikely; or

(iii) which may be required for use urgently so that their supply only on the prescription of a medical practitioner or veterinary surgeon would be likely to cause hardship.

Schedule Three substances may be supplied only by medical practitioners, authorized nurse practitioners, pharmacists, dentists or veterinary surgeons. Where such substances are supplied by a pharmacist, they must be personally handed to the patient by the pharmacist. Additional conditions may apply. Similarly, a veterinary surgeon should be personally and directly involved in the supply of any Schedule 3 preparation.

Schedule 4 (Restricted Substances)

Substances which in the public interest should be supplied only by a medical practitioner, authorised nurse practitioner, dentist or veterinary surgeon, or by a pharmacist on the written prescription of a medical practitioner, authorised nurse practitioner, dentist or veterinary surgeon.

Schedule 5

Poisonous substances of a dangerous nature commonly used for domestic purposes which should be readily available to the public but which require caution in their handling, use and storage.

Schedule 6

Substances which should be readily available to the public for agricultural, pastoral, horticultural, veterinary, photographic or industrial purposes or pest destruction.

Schedule 7

Substances of exceptional danger which require special precautions in their manufacture

Schedule 8 (Drugs of Addiction)

Substances which are addiction producing or potentially addiction producing. Possession, supply, prescribing and use are strictly limited. Provision is also made for substances to be rigidly controlled by subjecting their use or supply to special authority.

The legislation relating to poisons can be confusing if the relationship between the Act, the Regulations and the Poisons List or schedules is not readily understood. It can be easily understood by reference to Table 6.1, which explains how the legislative requirements complement each other in setting out specific provisions in each part.

TABLE 6.1 Overview of relevant poisons legislation

POISONS ACT	POISONS LIST OR SCHEDULES	POISONS REGULATIONS
Divides available poisons into specific schedules under broad headings as to type	Specifically identifies by generic the name the drugs or poisons that come under the different schedules	Spells out in detail requirements concerning such details as to the prescription, control, possession, storage, supply, and administration of drugs or poisons under the schedule headings in the Act

Clearly the three parts, so to speak, of the overall legislative provisions have to be applied in a complementary way. For example, the obvious question that any person would ask on reading the Act that identifies poisons into broadly defined schedules would be to inquire what specific drugs or poisons fall within those broad headings. To ascertain that information it is necessary to look to the complementary provisions. Specific requirements concerning such matters as authority to prescribe, control, possession, storage, supply and administration of the various types of drugs or poisons under the schedule headings will not be found in the Act. Such requirements will be found in the Regulations which accompany the Act and which are always in a separate document. As far as nursing staff are concerned, it is the Regulations that are the most important part of any poisons legislation, as they spell out precisely what must be done and observed in relation to the various substances, defined as poisons, that they deal with in the course of their work.

The specific schedules that are relevant to nursing staff are those generally identified as Schedule 4 substances and Schedule 8 substances. Schedule 4 substances are commonly referred to as restricted substances and cover all drugs that are able to be and are required to be provided on the prescription of a medical practitioner, dentist or veterinary surgeon. In New South Wales, authorised nurse practitioners are also able to prescribe specified Schedule 4 and Schedule 8 substances. The authorisation to do so must come from the Director General of Health in accordance with section 17A of the Poisons and Therapeutic Goods Act 1966, which reads as follows:

17A Director-General may authorise nurse practitioners to possess, use, prescribe or supply substances:

(1) The Director General may, by means of a written authorisation, authorise a nurse practitioner, or class of nurse practitioners, to possess, use, supply or prescribe any poison or restricted substance for the purposes of the practice of a nurse practitioner’s profession.

(2) Such an authority is to be given only if the Director General approves guidelines, under section 78A of the Nurses Act 1991, that provide for the possession, use, supply or prescription of poisons or restricted substances by nurse practitioners and is to be given in accordance with those guidelines.

(3) The Director General may amend or revoke any authorisation given under this section.

Apart from the Schedule 8 drugs, there are very few drugs that nurses administer on a day-to-day basis that do not come within Schedule 4. For example, such drugs as antibiotics, antihypertensives and anticoagulants clearly fall into Schedule 4, as they can be obtained only on prescription.

Some substances that nurses administer from time to time are not required to be provided on prescription. They are often referred to as ‘nurse-initiated medications’ and can be administered by nursing staff without a medical officer’s authority or prescription. These medications include substances such as Kaomagma or Panadol. Nurses should not automatically assume their right to administer such substances without reference, and should do so only in accordance with clearly written guidelines drawn up by the hospital or health authority. In New South Wales, authorised nurse practitioners are able to supply some Schedule 1 substances.

In some states and territories certain drugs are declared to be Schedule 4 substances but in terms of storage and security are required to be dealt with alongside Schedule 8 drugs. As an example, in New South Wales those specific drugs are set out in Appendix D at the back of the New South Wales Poisons and Therapeutic Goods Regulation 1994 and include such drugs as the barbiturates diazepam and paraldehyde. Schedule 8 substances are commonly referred to as drugs of addiction, but in Queensland they are referred to as dangerous drugs and in Tasmania as narcotic substances. Whatever the minor variation in titles, the type of drugs that come within this schedule are usually the narcotic analgesics such as opium, opium derivatives (morphine) and synthetic opium derivatives (pethidine).

The specific list of drugs under the various schedules changes fairly frequently as new drugs are developed and introduced. It is therefore essential that nurses be aware of this aspect and that any relevant addition or change to the list of drugs in Schedule 4 or Schedule 8 be communicated to them.

Hospitals are automatically notified of relevant changes to the poisons legislation by the state or territory health departments, generally by way of departmental circulars. To the extent that they are relevant, such circulars should be acted upon where necessary and distributed to all staff concerned.