Administering Medicines By Injection - Standard Operating Procedure
Important Notes before offering this service:
-
PDL encourages completion of an accredited medicines by injection course, as provided by the PSA and ACP:
- Confirm pharmacists Professional Indemnity insurance coverage
- Ensure administration is conducted professionally, is clinically appropriate, and ensure pharmacists are working within their scope of practice – including the skills and competency to administer the medicine.
- Comply with best practice guidelines (see Resources).
- Ensure clinical governance procedures are in place for service delivery, including systems for documenting occasions of service, referral, follow up with patients and incident reporting.
- Have knowledge of signs and symptoms of adverse reactions, and relevant management plans in place including an anaphylaxis management plan.
- Comply with all relevant state/territory legislation.
Purpose
- To outline the procedures for pharmacists to safely, legally, and competently administer medicines by injection, ensuring continuity of care and compliance with legislative and professional standards.
Scope
- Applies to the administration of all prescription and non-prescription medicines (excluding immunisations), including consumer consultation, injection, monitoring, and reporting (as per state/territory legislation)
State
Pharmacist initiated and administered
Administration with a lawful script
Trained internadministration
ACT
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
NSW
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
NT
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
QLD
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
SA
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
TAS
Unscheduled, S2, S3 and vaccines
Any scheduled or unscheduled medicine
Vaccines only
VIC
Unscheduled, S2, S3 and vaccines
Any scheduled medicine
Yes under qualified supervision
WA
Unscheduled and vaccines
Any scheduled or unscheduled medicine
Yes under qualified supervision
** current as of August 2025 – refer to your state/territory legislation
Authorisation Requirements
- Registration with Pharmacy Board of Australia
- Completion of accredited injection training (immunisation training)
- First Aid Certificate (renew every 3 years)
- CPR Certificate (renew annually)
- Anaphylaxis Management Training (approved course)
- Ongoing CPD relevant to injection practice
- Compliance with State/Territory legislation
Pre-Administration Requirements
Verify pharmacist’s authority and competence
Conduct product familiarisation
Prepare a private consultation area with:
- Seating/bed, hand hygiene station
- PPE, sharps container, waste disposal
- Anaphylaxis kit (with adrenaline), laminated protocol
Ensure at least one support staff with CPR, First Aid & Anaphylaxis training is present
Consultation Procedure
-
Review Consumer's Clinical Needs
- Prescription, medical history, allergies, previous reactions
- For unscheduled, S2 and S3 – establish a therapeutic need
- Discuss Medicine details, risks, benefits, costs, administration process
- Obtain Informed Consent (documented)
- Agree on Treatment Goals if multiple doses are needed
-
Dispense a consultation fee (suggested $25.00)
- Item ID: 496510 PHARMACIST INJECTABLES FEE
-
Dispense Works: search for fee *PHARMACIST INJECTABLES FEE
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FRED: Add the consultation (PHARMACIST INJECTABLES FEE) via Lists – Own brand drugs - Enter POS item maintenance and find product Item ID: 496510 PHARMACIST INJECTABLES FEE. Copy barcode and enter in APN field in newly created fee in FRED profile
- Direct patient to pay for medicine and administration.
- Use proper technique & aseptic method
- Perform double-check of medicine (if possible)
- Adhere to infection control and waste management procedures
Documentation:
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Ensure informed consent is collected and selected on the form (verbal consent is appropriate).
-
Document in real-time in MedAdvisor (detailed instructions here)
- Once medication is dispensed the patient will appear in MedAdvisor.
- Select Service for the patient
- Under Services, select Administration of Injection
- The dispensed medicine for injection will appear in MedAdvisor for selection.
Post-Administration Monitoring
Observe consumer per medicine-specific guidelines
-
Document observations and provide:
- Instructions for delayed reactions
- Information on support services
- Contact for urgent follow-up
Adverse Reaction Management
- Monitor and identify symptoms
- Provide first aid, call emergency services if required
-
Notify prescriber and document in:
- Health records, My Health Record (with consent)
- TGA reporting system
-
Record all interactions, including:
- Consent, administration details, monitoring as above
-
Communicate with healthcare team:
- Medicine administered, reactions, follow-up needs
- Access the GP advice letter or Service summary upon completion of the MedAdvisor form
-
Conduct regular reviews:
- Feedback from consumers and staff
- Adverse events and near misses
- Compliance with updated legislation
-
Maintain logs for:
- Adrenaline stock/expiry
- Training records
- Policy updates
- Use approved sharps containers and clinical waste bins
- Follow State/Territory waste management legislation
Emergency Protocol
- Anaphylaxis kit with 6 x adrenaline (1:1000) ampoules or auto-injectors
- Laminated anaphylaxis protocol visible at all times
- All staff trained in emergency response
- Replace used/expired adrenaline immediately
Review & Compliance
- Regular SOP reviews
-
Ensure all practice aligns with:
- PSA Professional Practice Standards
- National Competency Standards Framework
- Local legislation
Resources: