Reporting failure to give written prescription - s227 MPMR

This form must be used by a person or relevant manager to give notice about a prescriber’s failure to comply with a relevant provision relating to a prescription for a medicine.

A relevant provision means section 84(4), 92(3) or (4) or 100(2) or (3) of the Medicines and Poisons Regulation 2021 (MPMR).

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 227 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 227 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 person giving the notice

First name *

Last name *

AHPRA registration (if relevant)

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 227 (MPMR)

I am giving notice under s227 of MPMR of *

Failure to send the paper prescription to the person after sending a digital copy of a paper prescription for a medicine (section 84(4) MPMR) (OPTION 1)
Failure to provide a written prescription that confirms the oral prescription after orally prescribing an S4 or S8 medicine that was dispensed or given as a treatment dose (section 92(3) or (4) MPMR) (OPTION 2)
Failure to give a written prescription or sign another record made by the person at the time of the administration that confirms the oral prescription for an S8 medicine that was administered on the oral prescription (section 100(2) or (3) MPMR) (OPTION 3)

What type of S8 or S4 medicine/s were dispensed/administered after receiving a digital copy of a prescription?

Information: 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.

S8 or S4 Medicine	Unit description	Strength	Strength unit	Total number of units

What type of S8 or S4 medicine/s were orally prescribed for dispensing or giving as a treatment dose?

S8 or S4 Medicine	Unit description	Strength	Strength unit	Total number of units

What type of S8 medicine/s were orally prescribed for administration?

S8 Medicine	Unit description	Strength	Strength unit	Total number of units

Did you contact the prescriber to request a written prescription? *

If yes, please provide details

Emailed the prescriber or their place of practice
Telephoned the prescriber or their place of practice
Attended the prescribers place of practice to request the prescription
Notified the relevant manager of the prescriber
Verbally advised the prescriber that a notice to the chief executive would be given if the prescription was not provided
Advised prescriber in writing that a notice to the chief executive would be given if the prescription was not provided
Other

If other, please provide brief details

If no, please provide brief details as to why you have not contacted the prescriber

What was the outcome of these actions? *

Unable to speak to prescriber
Advised that the prescription was sent by mail
Advised that the prescription will be sent by mail
Advised that the prescriber will not send the prescription after orally prescribing
Advised that the prescriber will not send the original prescription
Other

If other, please provide brief details

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

Is there any supporting evidence available?

If yes, please ensure a copy of all supporting evidence is saved and available upon request if required.

Dispensing data that relates to the incident
Statements from staff
Copies of emails
Record of phone calls
Other

If other, please provide a brief description of available information:

Is there any further information that you are able to provide that may be relevant to this notice?

If yes, please provide details of any further information:

Please attach a copy of the written prescription if available

Certification *

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

MPMR-227, Version 1

Last updated: 1 July 2022