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Proprietor oversight audit areas

Pharmacy

Guideline

Published on 18 Mar 2024

Pharmacist proprietors must maintain an active interest in how their business is conducted, and ensure robust policies and procedures are in place. Proprietors should regularly audit compliance to legislation and procedures. The suggested audit areas are not exhaustive, they may assist to create and maintain documentation for compliance to proprietor oversight.

Schedule 3 example

  • Storage – are S3 medicines stored according to Regulation
  • Labelling – are all S3 medicines labelled with Pharmacy name and contact details
  • Pseudoephedrine – are all supplies recorded in Project Stop
  • Procedures for supply – Is there a written procedure for supply of S3 medicines and are all staff aware of the procedure 
  • High-risk S3 medicines – Is there a list of S3 medicines that may be misused/abused (e.g. Rikodeine, Restavit) 
  • Raise staff awareness on high-risk medicines, and check received orders against sales

Schedule 4

  • S4D balance check and report any loss to MOH
  • S4B prescriptions comply with legal requirements
  • Special Authority prescriptions (e.g. Acitretin and Isotretinoin) are written by prescribers with special authorisation 
  • monitoring the use of bar-code scanning to reduce medications errors
  • Refer to Support Resource for Managing High-Risk Medicines for more information

Schedule 8

  • Balance check (compulsory in March and Sep) and report any loss to MOH
  • S8 prescriptions are written in accordance to legislation e.g. computer generated
  • Prescription quantity and purpose of supply are deemed appropriate
  • Psychostimulant prescriptions have prescriber MOH approval (e.g. CNS, S28c, Ref No AU)
  • Only pharmacists have the safe key
  • Refer to the Dispensing Flow Chart for more information 

OTP

  • Complete the self-audit every 6-12 months for at least 15% of patients on OTP
  • Refer to the OTP Flow Chart for more information on documentation and dosing records

Prescription management

  • There is no legislation that permits ‘owing prescriptions’, however, emergency 7 day supply and PBS Continued Dispensing are allowed for eligible patients
  • Prescriptions from a phone/fax/email order outstanding more than 7 days are reported to MOH

DAA

  • Dispensing and packing protocol
  • Compliant Quality Care 2020 Requirements (Sub-Domain 5) 
  • Compliance with PPA Program Rules
  • Compliance with PSA DAA Guidelines

Vaccination

  • Compliant NSW Pharmacist Vaccination Standards
  • Appropriate documentation and records (e.g. patient screening/consent form, AIR)
  • Compliant Quality Care 2020 Requirements (Sub-Domain 8)

Last updated on 18 Mar 2024

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