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Pharmacy Services - SHED

This document provides a summary of best practice in relation to Pharmacy Services in SHED. The summary has been created to support staff during the Sunshine Hospital Emergency Department Redevelopment transition and early post-move period, and has been endorsed by the ED Leadership Team and SHED Pharmacy.


This QRG provides an overview of Clinical Pharmacy services within the Sunshine Hospital Emergency Department (ED).


This document summarises the relevant guideline so that all SHED staff can apply them. It also includes critical information related to SHED processes.


The SHED Nurse Unit Managers and Directors are responsible for ensuring that all relevant staff are appropriately aware of the Pharmacy service and processes related to medication administration.

Guideline/Process Details

Overview of the Clinical Pharmacy service

Basic Clinical Pharmacy Services are provided by designated clinical pharmacists allocated to WH EDs. Activities may include but are not limited to, clinical review; therapeutic drug monitoring; education on the use of devices, e.g. inhalers, spacers, adrenaline auto-injectors; assessment of a patient’s ability to manage their medication, including the provision of advice and information about dose administration aids; provision of medicines information to health professionals; provision of information for ongoing care and management; and adverse drug reaction management.

Clinical Pharmacy Referrals and queries

WH EDs do not have blanket clinical pharmacist referrals. A designated clinical pharmacist is available to accept verbal and electronic referrals from medical and nursing staff, Unit Managers or their delegates and pharmacy staff.

Simple medication supply queries are best directed to the Sunshine Pharmacy Department dispensary. Refer to Appendix 1 for an overview of the medication order supply process.  Urgent medication request can be escalated to clinical pharmacist directly to escalate to dispensary.

Escalation of medication-related issues (such as fridge temperature excursions and Schedule 8/11 discrepancies) should be done via the Senior Emergency Medicine Pharmacist (mob: 0435 962 527).

Medication Rooms in the SHED

All medication rooms in the new SHED (Fast Track (SEMFAST), Paediatric (SEMPAED), Resus (SEMRESUS), and Short Stay Unit (SSSU)), with the exception of the Ambulance Patient Offload Team Zone (SEMAV), The Hub and Behavioral Assessment Unit (BAU), are collocated with a clean utility room and have two proxy/swipe access safes (x1 safe for schedule 8 and x1 safe for schedule 11). Dual swipe card access is required for all new safes. All safes will be under camera surveillance. Existing safes will continue to require key access.

Medication Fridge Monitoring

All medication rooms in the new SHED have a medication fridge which will be monitored on BMS.

Centrally monitored fridges will still require temperature monitoring recorded on paper.

Should the fridge alarm, a pager will automatically be sent to the Nurse in Charge’s (NIC) phone. The NIC will then troubleshoot and escalate to engineering/pharmacy/AHA as required.

Supporting Documentation:

Document Governance

Title: Pharmacy Services – SHED
Version: 2.0
Date Published: May, 2022
Date of scheduled review: 01/07/2023
Author: Approver:
SHED Pharmacy SHED Leadership Team

Appendix 1: Medication order supply processes

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