NSW Health has published PD2019_058 “High-Risk Medicines Management Policy”.
The Policy Directive sets out the requirements for the safe management and the use of high-risk medicines within NSW Health facilities. It defines the requirements for establishing a high-risk medicine program that includes the development of a specific high-risk medicines register and the strategies to mitigate the risks associated with those medicines.
It sets out six mandatory requirements:
All public health facilities must maintain a high-risk medicines program in accordance with NSW Health Policy on Medication Handling in NSW Public Health Facilities.
All public health facilities must maintain as part of the high-risk medicines program, a specific high-risk medicines register. The specific high-risk medicine register must include medicines used locally within the facility identified to be at ‘high-risk’ of misadventure.
Local protocols must be developed for all identified high-risk medicines specified on the register. The protocols are to be developed in consultation with relevant specialists and overseen and approved by the District or Health Service Drug and Therapeutics Committee(s) (however named). Protocols must include a timeframe for review.
Each high-risk medicine protocol must include patient monitoring which is relevant and appropriate for the patient’s clinical circumstances. This is to ensure a timely response to adverse events or side effects associated with drug treatment.
All public health facilities should employ strategies to mitigate the risk of medicines on the mandatory local high-risk medicines registers.
Adverse incidents involving high-risk medicines must be reported in the facility incident management system and reviewed through local quality management systems.
The Policy Directive applies to Ministry of Health, Local Health Districts, Board Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Community Health Centres.
A copy of the PD can be found on the NSW Health website.