In Giving chief executive information about particular diversion-risk medicines - s233 MPMR

Giving chief executive information about particular diversion-risk medicines - s233 MPMR

Section 233 of the Medicines and Poisons (Medicines) Regulation 2021 (MPMR) requires a pharmacist to give notice to the chief executive in the approved form if the amount of a diversion-risk medicine being sought, other than a diversion-risk medicine that is also a monitored medicine, exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal.

This form must be used by the pharmacist to give notice to the chief executive unless the pharmacist has a reasonable excuse.

You may be contacted by an inspector appointed under the Medicines and Poisons Act 2019 or an authorised delegate of the chief executive to require further information and/or for auditing/inspection purposes relevant to this notice.

If, at this stage, you are not able to provide all the information in this notice, under section 233 of the MPMR you must give as much information as possible and you can provide any additional information or a follow-up notice at a later date.

Contact information

This notice is managed by Medicines Compliance.
Should you require assistance in completing this form,please email MedicinesCompliance@health.qld.gov.au

Privacy notice

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Queensland Health is collecting your personal information on this approved form under authority of section 233 of the MPMR. All personal information will be securely stored and only accessible by Queensland Health staff. Your personal information will not be disclosed to other third parties without consent,unless the disclosure is authorised or required by under law. Failure to provide information may render the form incomplete, which may constitute an offence under the Medicines and Poisons Act 2019. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at http://www.health.qld.gov.au/global/privacy

Required fields are marked with an asterisk (*).

Please indicate if this is the initial notice or follow-up notice *

Initial notice
Follow up notice

Please email additional information to MedicinesCompliance@health.qld.gov.au and include the initial notice Submission ID in the email title.

Please provide details of pharmacist giving the notice

First name *

Last name *

AHPRA registration *

Role within the business / organisation *

Contact number *

Email address *

Business / organisation details

Business / organisation name *

Street address *

Suburb *

State or Territory *

Postcode *

Is the contact number different to the one you provided earlier? *

Contact number

Is the email address different to the one you provided earlier? *

Email address

Section 233 (MPMR)

I am giving notice under section 233 of the MPMR that *

the amount of the particular diversion-risk medicine being sought exceeds the amount that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal.
the amount of the particular diversion-risk medicine being sought exceeds the frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal.
the amount of the particular diversion-risk medicine being sought exceeds the amount and frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal.

Why do you reasonably suspect the amount of the particular diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal? *

Reasonably suspect medicine is being diverted
Other

If other, please provide details

Did you dispense all/any of the particular diversion-risk medicines? *

Yes - full prescription
Yes - limited
No

Did you keep a copy of the prescription?

If yes, please attach a copy of the prescription

Please include details of the particular diversion-risk medicine/s that were dispensed/not dispensed?

Note:: Schedule 2, Part 3 of the MPMR provides a list of diversion-risk medicines. This form only relates to diversion-risk medicines that are NOT monitored medicines.

Information: Diversion-risk medicine/s should be listed using only the terms used in the Australian Standard of Uniform Scheduling of Medicines and Poisons (SUSMP/Poisons Standard). These terms do not include brand names of products, they only refer to active ingredients. If a substance is not listed in the SUSMP/Poisons Standard but is a derivative of one that is listed in the SUSMP, then select the substance that is listed.

Diversion-risk Medicine	Unit description	Strength	Strength unit	Total number of units

Please provide details of the prescriber?

First name *

Last name *

Type of prescriber *

If other, please provide a brief details of type of prescriber

Prescriber number (if applicable)

Business/organisation name *

Street address *

Suburb *

State or Territory *

Postcode *

Contact number *

Email address *

Did you contact the prescriber to discuss that the amount of the particular diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal?

Please insert date you contacted the prescriber

Day Month Year

What was the outcome when you contacted the prescriber?

Prescriber not available
Prescriber advised that prescription is correct
Prescriber advised the pharmacist to cancel the prescription
Prescriber advised the pharmacist that the prescription was fraudulent
Prescriber advised the pharmacist that the prescription was stolen
Other

Please complete s228 notice – reporting and preventing use of unlawful document or s 230 reporting supply on false prescription or purchase order (whichever relevant)

Please insert why the prescriber said to cancel the script

If other, please provide a brief description of outcome of contact with prescriber

Please provide details of why you did not contact the prescriber

Is there any supporting evidence available to confirm that the amount of a diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal?

Indicate all items that may apply

Dispensing data that relates to the incident
Statements from staff
Other

If other, please provide a brief description of available information

Certification *

In submitting this notice, I affirm that the information I have supplied is, to the best of my knowledge, true and accurate

MPMR-233, Version 1

Last updated: 20 October 2021