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19 February 2018

Impairment Committee Report: Management of controlled medicines/substances in healthcare establishments to minimise errors and abuse cause by improper control

1. Introduction

In healthcare establishments, registered nurses have a duty to control various medications, including controlled scheduled medicines and substances, i.e. those scheduled 5, 6 and 7. 

The shortage of qualified professional nurses in wards has the implication that ‘other categories’ of nurses are expected to participate in the co-checking of these medicines or substances. This has at times led to a departure from the policies and procedures governing the control of medicines and as such, lower categories of nurses and unauthorised personnel are sometimes left to check and administer these drugs on their own, without supervision.

 

2. Purpose

This Impairment Committee Report serves to reaffirm that nursing management has a duty to ensure that controlled scheduled medicines are properly managed, from the time these are ordered until they are administered to patients as prescribed by a medical practitioner, following proper policies and procedures.

 

3. Background 

The Impairment Committee of the South African Nursing Council (SANC) has noted with concern a degree of negligence in the manner in which controlled scheduled medicines are managed in some healthcare establishments (both public and private). 


The Impairment Committee, which is one of the standing committees established in terms of section 51 of the Nursing Act, 2005 (Act No.33 of 2005), is appointed to manage nurse practitioners (registered in terms of section 31 (1)(a-e) of the Act) who are deemed unfit to practice nursing due to disability or impairment. Cases of medicine and substance abuse are referred to the Committee, and it is frequently established that nurse practitioners have had access to drugs in the following ways:

bulletNurse practitioners being allowed to check and administer controlled scheduled medicines alone;
bulletThe keys of cupboards containing controlled scheduled medicine were not kept in the appropriate manner;
bulletThe amount of a medicine or injections remaining was supposed to be discarded, but the nurse in question appropriated it for her own use, because she handled the discarding process alone, and therefore had the opportunity.
bulletControlled scheduled medicines are not properly checked during every shift change, leaving discrepancies to go unnoticed;
bulletPrescribed medicines being administered recklessly, without counting/keeping record of the quantities of medicine having been administered to patients.
bulletThis information was forthcoming from nurse practitioners who, for example, were involved in car accidents or have had major operations (including caesarean sections) and were prescribed Pethidine, which led them to or contributed to their addiction.

 

4. Management of controlled medicines, schedules 5,6 and 7, in hospital departments and wards: 

4.1 Hospitals must adhere to policies and procedures in place to:

bulletPrevent;
bulletDetect; and
bulletReport any diversion (such as stealing and falsifying of records) of controlled medicines.

4.2 It remains the obligation of the registered nurse/midwife to ensure that all controlled scheduled medicines are ordered, controlled, administered and disposed of in terms of the given protocols, policies and procedures of the institution.

4.3 The registered nurse in charge of a nursing unit and/or shift remains accountable and responsible.

4.4 Enrolled nurses/nursing auxiliaries MUST NOT be allowed to keep the keys to the controlled medicines and substance cupboard and to check and administer scheduled medicines alone.

4.5 Unregistered staff (care workers and general workers) should not be involved in the administration of controlled scheduled medicines, or any medication.

4.6 Without a prescription by a doctor, there can be no administration of controlled scheduled medicines, except where a protocol is followed and in an emergency situation. The person in charge will remain accountable.

Note that the following are warning signs of nurses who may be abusing medicines and substances:

bulletHealth care users receiving the maximum prescribed dose of a pain injection (e.g. 100mg Pethidine), yet still experiencing increased pain;
bulletScheduled medicine to be discarded being kept in a syringe for no apparent reason;
bulletA nurse frequently borrowing scheduled medicines from other wards or visiting the wards/healthcare establishments at awkward times;
bulletA nurse asking colleagues to countersign in the register for scheduled medicines which they did not witness being dispensed;
bulletInaccurate recording and fraudulent entries;
bulletErasing or ‘overwriting’ of drug book entries, instead of following standard operating procedures; 
bulletOften volunteering to administer scheduled medications;
bulletFrequently offering to count scheduled medicines, to make sure the count is correct.

 

5. Legal obligations of the nursing service manager/ unit manager

Nursing service management must oversee the scheduled medicine control processes or procedures to ensure that all healthcare providers working in their healthcare establishment are strictly following these in terms of the given legislation.

It is therefore important that nursing management ensure adherence to the standards as laid down by:

bulletThe Medicines Control Council;
bulletThe National Drug Policy for South Africa;
bulletThe rules relating to Good Pharmacy Practice in South Africa;
bulletThe Medicines and Related Substances Act, 1965 (Act 101 of 1965).

 

Behaviours indicative of Controlled Medicine abuse 

These may include, but are not limited to the following:

bulletA noticeable decrease in attendance at work, increased absence or reporting late for work.
bullet A noticeable decrease or inconsistency regarding work performance
bulletMood swings
bulletDeterioration in personal appearance.
bullet May be sleepy or dozing off while on duty.
bulletNot interested in interaction with others, or being withdrawn.
bulletMemory lapse or euphoric recall of events.
bulletMay have ‘pin point’ pupils, shaky hands or tremors.
bulletSmelling of alcohol, or mouthwash/breath mints to mask the alcohol smell.

 

Common group of Controlled Scheduled Medicines abused by health practitioners 

Like anyone, nurses can and do use many different types of medication. Some are legitimate prescriptions issued after consultation with medical doctors. Some, like pain or allergy medication can be bought over the counter.

Those used in health establishments fall within the following categories:

bulletBarbiturates, benzodiazepines and tranquilizers, such as Diazepam;
bulletPrescription painkillers, such as opiates;
bulletSedatives, such as Propofol or Diprivan;
bulletAppetite suppressants and narcotic analgesics.

A LIST OF SCHEDULED SUSTANCES IS AVAILABLE IN THE MEDICINES AND RELATED SUBSTANCES ACT NO. 101 OF 1965.

 

Some SUBSTANCES are recreational, such as: 

bulletAlcohol;
bulletMarijuana and other ‘street drugs’.

 

Getting Help

Most public and private health establishments have Employee Assisted Programs to support their staff, including assistance for nurses with substance abuse problems.

The South African Nursing Council, like other health statutory bodies, offers an alternative to discipline program for nurse practitioners who demonstrate signs of impairment in terms of section 51 of the Nursing Act, 2005 (Act 33 of 2005).

To contact the SANC please use the following information:

Postage or hand delivery

Tel No. 27+12 420 1008/426 9547

The South African Nursing Council
602 Cecilia Makiwane Building
Arcadia, 0083 

Email: gash@sanc.co.za or 
skubayi@sanc.co.za

 

 

References

bullet‘Scheduling of Medicine guidelines’– Medicine Control Council;
bulletMedicine and Related Substances Act, 1965 (Act No. 101 Of 1965);
bulletNursing Act, 2005 (Act No. 33 of 2005);
bullet‘Good Pharmacy Practice Manual’ – South African Pharmacy Council;
bullet‘Safe Management of Controlled Drugs: A guide to good practice in secondary care (England)’ – British Department of Health;
bulletwww.rehabcenterrankings.com/drug-addiction-in-healthcare-professionals;
bulletwww.nevadanursingboard.org/

 

 


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