Reporting supply on false prescription or purchase order for diversion-risk medicine - s230 MPMR

Section 230 of the Medicines and Poisons (Medicines) Regulation 2021 (MPMR) requires the supplier of a diversion-risk medicine to give notice to the chief executive if, after supplying a diversion-risk medicine on a prescription or purchase order, they reasonably suspect any of the following incidents has happened:

false information, material to the prescription or purchase order, was given to the person who prescribed the medicine or gave the purchase order;
the prescription or purchase order was changed by a person other than—
1. for a prescription—the prescriber of the prescription or the dispenser of the medicine for the prescription; or
2. for a purchase order—the person who gave the purchase order;
the prescription or purchase order was false in any material particular.

This form must be used by the supplier to give notice to the chief executive.

By way of note, if a supplier becomes aware of a potential incident before providing a diversion-risk medicine, they must complete the Reporting and preventing use of unlawful document pursuant to section 228 of the 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 230 of the MPMR you must give as much information as possible and you can provide any additional information when available.

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 230 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.

Was the diversion-risk medicine dispensed/supplied? *

Yes – full
Yes – partial
No

Do not complete this notice. Complete the Reporting and preventing use of unlawful document pursuant to section 228 of the MPMR

Please provide details of supplier making the notice

First name *

Last name *

AHPRA registration (if relevant)

Role within the business / organisation *

Contact number *

Email address *

Business / organisation details

Substance Authority reference number (if applicable) e.g. substance authority number (Queensland licensees), licence or authority number (interstate licensees and Commonwealth licensees) or a pharmacy business number

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

What type of document is this notice for? *

A purchase order
A prescription

Please include details of the diversion-risk medicine/s that were supplied?

Note: Schedule 2, Part 3 of the MPMR provides a list of diversion-risk 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

I am giving notice under section 230 of the MPMR that I reasonably suspect that

False information was given to the person who gave the purchase order
The purchase order was changed by a person other than the person who gave the purchase order
The purchase order was false in any material particular

If false information was given to the person who gave the purchase order

False name and address details
False identification documents provided
Other

If other, please provide a brief description of incident

If the purchase order was changed by a person other than the person who gave the purchase order

Additional items were added to purchase order
Date of purchase order was altered
Quantity of medicine was altered
Strength of medicine was altered
Other

If other, please provide a brief description of how purchase order was changed

If the purchase order was false in any material particular

Photocopied or scanned purchase order
Other

If other, please provide a brief description of how the purchase order was false in any material particular

Can you provide a copy of the purchase order?

Please attach a scanned copy and provide the purchase order details listed below

Please provide details of the person who gave the purchase order?

First name

Last name

Type of supplier

If other, please provide a brief details of person who gave the purchase order

Prescriber number (if relevant)

Business/organisation name

Street address

Suburb

State or Territory

Postcode

Contact number

Email address

How was the unlawful supply discovered?

Suspicious behaviour noted by staff after supplied
Received information from another pharmacy/pharmacist
Received information from supplier
Reported by patient
Reported by member of the public
Other

If other, please provide a brief description of how unlawful supply was discovered

Please include details of the diversion-risk medicine/s that were dispensed?

Note: Schedule 2, Part 3 of the MPMR provides a list of diversion-risk medicines

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

I am giving notice under section 230 of the MPMR that I reasonably suspect that

False information was given to the person who gave the prescription
The prescription was changed by a person other than the prescriber of the prescription or the dispenser of the medicine/s
The prescription was false in any material particular
Other

If other, please provide a brief description of incident

If false information was given to the person who gave the prescription

False name and address details
False identification documents provided
Other

If other, please provide a brief description of false information that was given to the person who gave the prescription

If the prescription was changed by a person other than the prescriber of the prescription or the dispenser of the medicine/s

Additional items were added to prescription
Date of prescribing was altered
Quantity of medicine was altered
Strength of medicine was altered
Number of repeats was altered
Other

If other, please provide a brief description of how prescription was changed

If the prescription was false in any material particular

Photocopied or scanned prescription
Repeat authorisation form was copied or scanned
Other

If other, please provide a brief description of how prescription was false in any material particular

Can you provide a copy of the prescription?

If yes, please attach a scanned copy and provide the prescription details listed below

Was the person presenting the prescription, the person for whom the prescription was written?

Yes
No
Unsure

Can you provide the name and physical address details of the person who gave the prescription?

Please provide details below

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 relevant)

Business/organisation name

Street address

Suburb

State or Territory

Postcode

Contact number

Email address

How was the unlawful supply discovered?

Suspicious behaviour noted by staff after supplied
Received information from another pharmacy/pharmacist
Received pharmacy alert issued by Queensland Health
Received pharmacy alert issued by Pharmacy Guild
Received information from prescriber
Reported by patient
Reported by member of the public
Other

If other, please provide a brief description of how incident was discovered

Has this incident been reported to the Queensland Police Service (QPS)? *

Do you have a QPS reference number for the report made?

If yes, please enter the QPS reference number

Is there any evidence available to confirm the incident?

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

Closed-Circuit Television (CCTV)
Dispensing data that relates to the incident
Statements from staff
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

Certification *

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

MPMR-230, Version 1

Last updated: 20 October 2021