19 February 2018

Impairment Committee Report: Management of controlled scheduled medicines/substances in healthcare establishments to minimize errors and abuse caused 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:

	Nurse practitioners being allowed to check and administer controlled scheduled medicines alone;
	The keys of cupboards containing controlled scheduled medicine were not kept in the appropriate manner;
	The 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
	Controlled scheduled medicines are not properly checked during every shift change, leaving discrepancies to go unnoticed;
	Prescribed medicines being administered recklessly, without counting/keeping record of the quantities of medicine having been administered to patients.

o This 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:

• Prevent;
• Detect; and 
• Report 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:

	Health care users receiving the maximum prescribed dose of a pain injection (e.g. 100mg Pethidine), yet still experiencing increased pain;
	Scheduled medicine to be discarded being kept in a syringe for no apparent reason;
	A nurse frequently borrowing scheduled medicines from other wards or visiting the wards/healthcare establishments at awkward times;
	A nurse asking colleagues to countersign in the register for scheduled medicines which they did not witness being dispensed;
	Inaccurate recording and fraudulent entries;
	Erasing or ‘overwriting’ of drug book entries, instead of following standard operating procedures;
	Often volunteering to administer scheduled medications;
	Frequently 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:

	The Medicines Control Council;
	The National Drug Policy for South Africa;
	The rules relating to Good Pharmacy Practice in South Africa;
	The 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:

	A noticeable decrease in attendance at work, increased absence or reporting late for work
	A noticeable decrease or inconsistency regarding work performance.
	Mood swings.
	Deterioration in personal appearance.
	May be sleepy or dozing off while on duty.
	Not interested in interaction with others, or being withdrawn.
	Memory lapse or euphoric recall of events.
	May have ‘pin point’ pupils, shaky hands or tremors.
	Smelling 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:

	Barbiturates, benzodiazepines and tranquilizers, such as Diazepam;
	Prescription painkillers, such as opiates;
	Sedatives, such as Propofol or Diprivan;
	Appetite 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:

	Alcohol;
	Marijuana 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 

References

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