Schedule 4 (S4) & Schedule 8 (S8) Medications

Participant Support Procedures > Schedule 4 (S4) & Schedule 8 (S8) Medications

Authorised by Chief Executive Officer

Revised Date: 4 June 2025

Purpose

This procedure outlines the process for the management, administration, and documentation of Schedule 4 (S4 and S4D) & Schedule 8 (S8) drugs as part of NDIS service delivery.

This procedure supports Kyeema to apply the NDIS Practice Standard 4.3 Management of Medication

Scope

This procedure applies to all workers involved in the access, administration, storage, and documentation of S4, S4D & S8 drugs.

Related legislation and policy

Drugs, Poisons and Controlled Substances Act 1981

Drugs, Poisons and Controlled Substances Regulations 2017

Medicines and Poisons Act

Victorian Therapeutics Advisory Group (VicTAG) Guidelines

https://www.health.vic.gov.au/public-health/medicines-and-poisons-regulation

Definition

Schedule 4 (S4) medications: Prescription medicines with lower control requirements e.g. Sertraline and Mersyndol.

Schedule 4D medications (S4D): Subset of S4 medications, ‘Prescribed Restricted Substances’ - includes benzodiazepines (like Diazepam) & strong analgesics. Require strict storage & recording eg. Mersyndol Forte.

Schedule 8 medications: Controlled substances due to their potential for abuse or dependence. Require strict regulation and documentation. E.g., medical marijuana, oxycodone.

Procedure

Schedule 4D (S4) and Schedule 8 (S8) medications that are used for PRN purposes need storage in a locked cupboard and requires strict monitoring via use of a Medication Record.

Best practice for Schedule 4, 4D and Schedule 8 drugs is to check and sign off the balance during shift handover, and sign again at the time of administration.

Table 1. Summary Medication Storage and Stock Balance

Instructions:

1.  All S4, S4D & S8 medications are to be kept in a locked cupboard or safe that is not accessible to any person/s except authorised individuals.

2.  Two staff are to check medication balance at the beginning of each shift, record & sign the Drug of Addiction Administration Book

3.  If medication is required, complete Drug of Addiction Administration Book. Two signatures are required to sign out medication. Second signature can be via phone call authorisation from On Call Staff, in cases when only one Staff is on shift. Record in pen and the ON-Call worker records the count in case notes.

4.  Low stock medication when inventory is completed, house supervisor will order through pharmacy to be delivered at next scheduled delivery.

5.  Medication received from Pharmacy or returned to the Pharmacy (i.e. expired

medication) should be recorded in pen, double signature required by at least one supervisor

6.  If any medication has signs of being tampered with or Medication Balance is not

correct contact Manager / Supervisor immediately and complete incident report.

Emergency Use Outside the Home if a participant requires S4/S8 PRN medications during community access or activities, these must be taken in accordance with their Individual Management Plan and, if applicable, Epilepsy Management Plan. These medications are packed as an Emergency Medication Pack, which must be:

•      Documented in the Medication Record.

•      Checked for return or usage upon the participant’s return.

•      Recorded in the Drug of Addiction Administration Book.

Medical Marijuana – S8

•      House supervisor assists with appointments and ordering all medications.

•      Medical Marijuana is ordered through an app on the participants phone and is delivered via post

Secure Storage:

•      S4 drugs must be stored in a locked, secure cabinet or cupboard to prevent unauthorised access. Only authorised workers may have access to the keys or codes.

•      S8 drugs must be stored in a locked, secure drug cabinet / safe firmly fixed to the wall or floor. Only authorised workers (e.g., managers / supervisors) may have access to the keys or codes.

Monitoring Side Effects

Workers are to monitor the participant for possible side effects and report immediately.

•      CCF- 78 Medication Effects & Side Effects

Incident reporting for PRN S4 & S8 medication

CCF-65 Incident, Complaint, WHS Record Form

1.  Theft or Misappropriation:

o  Any theft, pilferage, or misuse of medications by staff or others.

2.  Medication Administration Errors:

o  Examples include the administration of the wrong drug or incorrect dosage to a participant/resident.

3.  Stock Discrepancies:

o  Any unexplained differences between medication records and the actual stock on hand.

4.  Procedural Failures:

o  Minor, explainable discrepancies that were not detected through routine procedures, indicating potential issues in current checking protocols.

Disposal of S8 Drugs

•      Proper Disposal: If any S8 drugs are no longer needed or are expired, they must be disposed of in a lawful and safe manner. Take the medication and the Drug of Addiction Administration Book to the pharmacy so that the pharmacist can check and sign that the correct amount of medication is being returned for disposal.

•      Record of Disposal: The disposal of any S8 drugs must be documented in the Drug of Addiction Administration Book, noting the amount disposed of, the date, and the method of disposal.

Record Keeping

S4/S8 not in Webster packs (use the Drug of Addiction Administration book)

•      Drug of Addiction Administration Book

The register is a book where drug administration can be recorded. The pages of the book must be consecutively numbered; and the spine of the book must be bound, so it would be obvious if a page was torn out.

S4/S8 in Webster packs use PRN forms e.g.CCF-04 PRN (as required) Medication Record Sheet.

All records are to be kept for at least 3 years.

Training and Competency

Staff Training: All staff members who are involved in the handling or administration of S8 drugs must receive specific training on:

•      the handling and storage of controlled substances

•      the NDIS standards and drug law compliance

•      recognising and reporting adverse reactions

•      completing necessary documentation

Competency Assessment: Workers must undergo periodic competency assessments to ensure they are following procedures correctly

Regular Audits: There should be regular audits of the S8 & S4D drug register and storage systems. This ensures that drugs are being used correctly, recorded accurately, and that there are no discrepancies or misuse.

Internal Reporting: If any discrepancies or breaches in procedure occur, they must be reported immediately to senior management and resolved as soon as possible.

Related Policies, Procedures and Documents

Use of Health Monitoring Tools and PRN Webster Packs

CCF-65 Incident, Complaint, WHS Record Form

CCF-78 Medication Effects & Side Effects

CCF-04 PRN (as required) Medication Record Sheet.