Investigation Report - Drugs

1. Description of the incident

On 30 June 2016 an email was received from Director of Pharmacy advising of a drug discrepancy of 9
x clonazepam 2mg tablets (DS4) reported missing from pharmacy on 29 June 2016. Drugs is listed
under the Queensland Health (Drugs and Poisons) Regulation 1996. The stack count on the
28/06/2016 was recorded being tablets. There was a distribution of 20 tablets to EDSSU on the
24/06/2016 and the person in charge recalled counting the amount of tablets, but did not have a clear
memory of counting the remaining tablets.
Clonazepam is listed as a CD4 under the Controlled Drug (S8) or Designated Drug (DS4) Gold Coast
Hospital and Health Service. This requires pharmacies and hospitals to lock the drugs in a safe place
and counting them with every change of working shift. Counting has to be conducted by two people,
for example a registered nurse and a second person as a witness. Any discrepancy has to be
immediately reported to the director of pharmacy.
Pharmacy staff already

Checked the distributions and orders for clonazepam 2mg and .5mg;

Checked all disposals;

Checked all returns of clonazepam;

Checked the count of clonazepam 0.5mg (all balanced);

Physically checked the count of clonazepam and CD books on wards C3W and EDSSU as they
were the only wards that had received clonazepam 2mg on 28 June 2016 and 29 June 2016

Checked lorazepam in case the wrong drug had been dispensed (all matched); and

Physically checked the floor, fridge, night cupboard and safe for loose tabs.
The Director of Pharmacy reported also that they had reviewed the CD safe swipe card entry records
and there was no indication that anybody had entered the CD safe that was not authorised to enter.
A list of employees who were working in the CD safe area preparing the ward orders when the
discrepancy was identified and the preceding day was made. Furthermore the Director of Pharmacy
provided paperwork of all transactions, returns, Ipharmacy stock movement etc. There had been one
return of clonazepam to pharmacy from C4E on 27/06/2016 conducted by a pharmacist and this
consisted of 8 x tabs of clonazepam 2mg and 1 x tablet of clonazepam 0.5mg

2. The role of the enforcement agency involved

The role of the GCPHU under the Controlled Drug (S8) or Designated Drug (DS4) Gold Coast Hospital
and Health Service was to investigate the case, because it is considered as a minor incident and is
therefor directed to the unit for an internal investigation. The aim is to find out if it was a criminal act
or a matter of bad book keeping and/or bad handling practises of drugs. For this, the Department of
Pharmacy (DOP) is sending out a request to the Gold Coast Public Health Unit to investigate the case
and report results back to the DOP.

3. Relevant Legislation, Standard, Code

Queensland Health (Drugs and Poisons) Regulation 1996
The Health (Drugs and Poisons) Regulations 1996 (HDPR), is the legislation that governs medicines
management, storage and access in Queensland
Controlled Drug (S8) or Designated Drug (DS4) Gold Coast Hospital and Health Service
This document outlines the Gold Coast Hospital and Health Services (GCHHS) procedures for applying
that legislation specifically for CD (CD) and Designated Schedule 4 medications (DS4). The procedures

are intended to ensure the safe use of these medications while providing detailed guidance on how
to operationally apply the requirements of the Regulations, in addition to Queensland Health (QH)
corporate policies. These procedures apply to all staff working within the Hospital and Health Service
(HHS) in all settings, during the performance of their required duties.

4. Normal Procedure for CD4 and SD in Pharmacies

In the Pharmacy Departments, all transactions will be processed through the State-wide Pharmacy
Information Management System (QHPIMS). However, at present, these records do not meet
Legislative requirements as the sole record for a transaction and therefore manual records must also
be maintained. The way of making records is documented in the Pharmacy department specific work
instructions. Every form and every strength of a drug will generally have its own register, except in
unusual circumstances of an item that has very infrequent usage.
Within the pharmacies, CD/DS4 will be stored at all times in the approved safe. This will include all
inventory, dispensed medication and medication waiting for destruction. The combination of the safe
will be known only to pharmacists. Suitably qualified dispensary assistants will have daytime access to
the safe to perform their imprest and dispensing duties under the personal supervision of a
pharmacist.
The safes at both Robina hospital and GCUH support individual access codes and swipe cards and their
use will be regularly reported and audited. Access codes will be set up and maintained by the Director
and Assistant Director of Pharmacy.

5. Investigation
The appropriated procedure to be followed in possession, storage, distribution and the use of CDs and
DS4 is written out in the QLD Health Controlled Drugs (CD) and Designated Schedule 4 (DS4) Medicines
Management, Gold Coast Hospital and Health Service document. In accordance to the information
given in point 4 (Normal Procedure for Cd4 and SD in Pharmacies) of this report , the officer undertook
the following investigation measures:
The officer met with the Director of Pharmacy who advised that following action were taken by
pharmacy staff to locate the clonazepam:

Checked the distributions and orders for clonazepam 2mg and .5mg;

Checked all disposals;

Checked all returns of clonazepam;

Checked the count of clonazepam 0.5mg ( all balanced);

Physically checked the count of clonazepam and CD books on wards C3W and EDSSU as they
were the only wards that had received clonazepam 2mg on 28 June 2016 and 29 June 2016
respectively ;

Checked lorazepam in case the wrong drug had been dispensed (all matched); and

Physically checked the floor, fridge, night cupboard and safe for loose tabs
Furthermore the Director of Pharmacy undertook the following actions to help to identify the cause
of the missing drugs:
advised that they had reviewed the CD safe swipe card entry records
list of employees who worked in the Cd safe area at the time

paperwork (refer folio 2) of all transactions, returns, Ipharmacy stock movement etc.
The officer undertook the below described actions to investigate the case after receiving all tge
information from the Director of Pharmacy:
Reviewed the CD book for the clonazepam and confirmed the count was correct.
Interviewed stuff of the pharmacy department
Request official statement of all involved people

Conduct a count of the clonazepam and check the CD book and all balanced
check all Pharmacy CD order forms for June

6. Identification of potential offence

The investigation revealed no provable offence for any investigated person.

7. Findings & Conclusions

It is possible that the 9 x Clonazepams were stolen by a person within pharmacy and with
access to the CD safe, however the officer was unable to determine who may be responsible

Whilst the officer was unable to account for where or how the clonazepam was taken, the fact
that it was the pharmacists first 2 days working in that position in the pharmacy I cannot discount
that there has been an error made somewhere but it could not identified where in the system

In addition the officer feels that if a person was going to steal drugs the question arises why
would they take 9 x Clonazepams an S4 drug when they could take any number of controlled drugs
from the safe. Further Clonazepam and other S4s are disposed of in the purple discard bins within
pharmacy and can be easily accessed without going into the safe. In addition the drugs in the purple
bins are not accounted for and would not raise any suspicion if taken

8. Options for resolution & future improvement

In accordance with the pharmacy unit management the following actions will be taken to
ensure that similar cases will not occur in the future.

Recommendation for a CCTV camera to be installed in the pharmacy CD safe

Ensure all stuff is well trained in bookkeeping
Allow extra time, especially for new team members, to allow proper bookkeeping and
counting of drugs

These actions were suggested by the pharmacy unit itself as a proactive action and to demonstrate
the will to fulfil legislation requirements.

9. Recommended course of actions

No further action required

But an EHO will be always available to answer questions and help to solve arising problems
within the pharmacy unit to support and ensure that legislation requirements are met