Illicit use of stolen green whistles at work party

As the holiday season approaches and the partying begins, make sure this is done safely by minimising the risk of medication misuse. Based on real cases, this story serves as a stark reminder for practices to have robust medication controls in place.

Stolen medication

A practice manager was scrolling through Facebook when she saw photos from the receptionist’s page showing practice staff inhaling from green whistles (methoxyflurane inhalers) at the end-of-year work party. Her heart sank even further when she recognised the medication label ─ the green whistles had been prescribed by a doctor at her practice.

After investigating, the practice manager discovered a registered nurse employed by the practice had taken the green whistles from the emergency trolley and passed them around at the party.

The practice manager advised the nurse about her concerns and said her employment would be suspended pending a workplace investigation. The nurse immediately admitted to taking the green whistles and resigned.

Managing the implications

This type of breach can have significant ramifications for a practice. The issues include employment processes, mandatory reporting obligations and review of medication controls, policies and training.

As a first port of call, the practice manager should report the missing medication to the relevant state drugs and poisons regulator, and the police.

The practice will also need to make a mandatory notification to the Nursing and Midwifery Board about the nurse’s theft of medication from the practice.

Medication process audit

In these situations, we recommend practices undertake a detailed audit of medication processes and policies.

The practice manager discovered the nurse was solely responsible for ordering medication for the emergency trolley and a doctor would simply sign the medication order without checking it.

The nurse also received the medication and stored it on the emergency trolley without any oversight. Couriers would drop parcels directly to the nurse’s room rather than leaving them at reception and medication was often left in the unlocked room, creating an opportunity for theft.

Review of practice policy

The practice updated their practice policy and processes on the management of the emergency trolley medication. This included determining what medication was really necessary for the trolley and requiring a two-person check for ordering, receiving, and disposing of medication.

Staff who attended the party were reminded about appropriate behaviour at a work function and the practice policy about not publishing photos from a staff party on social media.

Medication storage and security

The scenario above reinforces the importance for practices to consider whether S4 and S8 medications need to be kept at the practice in the first place.

If your practice decides medications don’t need to be kept onsite, ask a retail pharmacist to destroy the medications. You may wish to place a sign at the entrance to the practice flagging that no drugs of addiction are stored on the premises.

S4 and S8 medications must be stored in accordance with relevant state legislation (i.e. in a room which the public cannot access).

To ensure tighter security, we recommend code locks, rather than key locks, on the medication cupboard. You should decide which authorised staff will have access to the code and how often the code will need to be changed.

If your practice is using a key lock, ensure the key is stored overnight in a secure locked area (preferably a safe) that only authorised people can access.

It’s essential to have a policy in place on medication storage and security, accountability and which staff have access to the medications. The policy should include a two-person process (one person should be a doctor) for checking the medication, and all relevant staff need to be trained on the policy.

Finally, all prescription pads should be locked up overnight and the first and last numbers on any unused prescription pads registered in an excel spreadsheet. To minimise the risk of stolen handwritten scripts, any empty script pads should be swapped for a new one. This also allows practices to track the script pad if theft occurs.

Is your practice prepared?

Avant practice policy holders can contact the medico-legal advice team on 1800 128 268, 24/7 in emergencies. Not an Avant practice policy holder? Protect your practice from risk and uncertainty with our suite of practice solutions.