Only licensed nurses may receive, administer, waste, borrow, or count controlled drugs. Licensed physicians may only administer or waste controlled drugs.

1. RECEIVING CONTROLLED DRUGS:

Authorized Pharmacy personnel deliver controlled drugs to the nursing unit daily. The nurse who receives the delivery is responsible for checking the drugs delivered prior to signing for acceptance of the drug.

On areas not using Pyxis machine the nurse receiving the controlled drugs from the Pharmacy is responsible for checking the number on the container with the number on the Controlled Drug Administration Record (CDAR). In addition, the nurse checks that the amount delivered is the same as the amount indicated on the CDAR. After completing the check, the nurse signs the receipt for the drug and places the drug in the locked drug box. See Guideline O.

On areas with Pyxis med station the pharmacy adds controlled drugs to the Pyxis with a nurse witnessing the entry. If there is a discrepancy with the controlled drug count prior to the delivery, it must be resolved before any addition(s) is made. The Pyxis printout is signed by the witnessing nurse and returned to the pharmacy personnel.
Controlled drugs may be received by the pneumatic tube system using the "secure transaction" feature. Pharmacy personnel will enter all relevant data on the Secure Transaction Log. The nurse receiving the authority code must retrieve the narcotic, sign the narcotic slip and indicate the time the drug is administered and return it to the pharmacy immediately via pneumatic tube.

 

2. ADMINISTERING CONTROLLED DRUGS:

On areas not using Pyxis, record keeping of controlled substances inventories for each drug, dose form, and strength is accomplished by the nurse on the Controlled Drug Administration Record. Each unit of drug is to be accounted for. The nurse who administers the drug records the used drug on the Controlled Drug Administration Record. See Guideline O for further information. The drugs used on the patient are charged using a preprinted daily charge sheet.  These sheets are picked up daily by the pharmacy.

The nurse administering the last dose of any controlled drug is responsible for checking the Controlled Drug Administration Record sheet for completeness. Incomplete sheets will not be accepted in Pharmacy for refill.

Differences of inventory and record accounting must be resolved by nursing staff before a new supply can be issued. The inpatient Pharmacy may be asked to advise on record-keeping procedures only.

In rare instances, after assessment by a physician and notification of the nursing administrator, it is permissible for the physician to administer a single dose of a controlled drug to a member of a patient's family.

The physician must:

1. Assess the family member for allergies, health problems, and need for medication before administration of the drug.
2. Write an order in the patient's chart.
3. Document his assessment and administration of the drug in the Progress Notes on the patient’s medical record.

The nurse will:

1. Inform the Nursing Administrator on duty of physician's decision prior to administration of the medication.
2. "Sign out" the drug on the Controlled Drug Administration Record to the patient, with the words "for family member" added.
3. Assure that others attend the family member before drug is administered or family member leaves the hospital.

Drugs are not to be given to any family member to be taken home.

Controlled drugs may not be sent off the unit with or for a patient. Neither may a physician obtain a dose on his/her signature to be removed from the unit. The nurse signing out the drug must administer or witness the administration of the drug.  Exception:  In surgery or labor and delivery the nurse may obtain a controlled substance for an anesthesiologist utilizing controlled drug requisition forms as set by pharmacy policy.

3. WASTING CONTROLLED DRUGS:

Dispose of contaminated, wasted, or refused controlled drugs according to following procedure. All wastage is to be observed and documented by another licensed nurse or physician.

Oral Solids – The medications will be flushed with water into the sink in the mediation room in front of a witness.

Oral Liquids – The medication will be discarded into the sink in the medication room in front of witness.

Ampuls and single dose syringes – Excess amounts will be wasted and witnessed in the medication room before the dose is given. All the liquid in an ampul will be drawn into a syringe and the excess will be pushed into the sink in front of a witness.

Narcotic Patches- Any narcotic patches should be folded, sticky side together and discarded into the sharps container.

Morphine for titration in the intensive care unit – A 10mg/10ml syringe may be used for intermittent doses by one nurse for the duration of the shift. Any remaining solution at the end of the shift shall be wasted with a witness.

Morphine for titration in the PACU – A 10mg/10ml syringe will be used during the patient’s stay in the PACU. Amounts administered from the syringe will be recorded on the PACU record. Any drug remaining when the patient is discharged from the PACU will be wasted.

Large volume IV/epidural bags – If there is fluid remaining in the bag when it is discontinued, the remainder of the bag will be wasted in the medication room sink in front of a witness. Wastage will be documented (in mg and ml) on the single dose administration record which is then returned to the pharmacy or on the nursing flow sheet on the time slot when the drug was discontinued.

PCA syringes shall be removed from the pump. The emptied syringe may be discarded in the sharps container.  Wastage will be documented in the patient record and verified with both signatures.

4. BORROWING CONTROLLED DRUGS:

Borrowing from another unit should only occur for single doses.

The nurse who desires to borrow the drug will notify the Nursing Administrator on duty or Pharmacist of the need to borrow (Assistant Director of Nursing (ADON) on Evenings, Nights, Weekends and the Clinical Service Manager(CSM), or Nursing Director on Days). The Nursing Administrator or Pharmacist in turn will notify the lending unit that a nurse from another unit will be borrowing a specific controlled drug from their stock. It is the responsibility of the lending unit to obtain from their narcotic box or Pyxis the drug being borrowed, assure that the drug is documented according to usual procedure and verify that the nurse receiving the drug has proper identification (hospital ID).

5. COUNTING CONTROLLED DRUGS:

On areas not using Pyxis a daily record of the total amount of controlled drugs on the unit is maintained. The Daily Controlled Drug Audit Record is completed every shift change - no less than two (2) or more than four (4) times daily. A shift-to-shift inventory & records review is required. A member of the "off-going" shift and the "on-coming" shift must count controlled drugs according to procedure. All drugs must be accounted for before the "off-going" shift leaves. Any unexplained discrepancy must be reported to Nursing Administration and pharmacy. See Procedure 52 and Guideline M for further information.

In areas using Pyxis a complete inventory of controlled drugs is performed every Monday and Thursday. In the event an inventory of controlled drugs is missed the count is completed the next day.  An inventory is completed upon closing and then reopening a unit that is temporarily closed.

At the end of each shift, the Care Delivery Facilitator (CDF) will check a review of all controlled drug transactions by user. Any indications of excessive waste will be reported to the Clinical Services Manager (CSM) for follow up. The user review will be documented on the user/discrepancy log.  Each individual staff nurse working on the shift must review the record of controlled substances which he has used and verify the accuracy by signing the "Pyxis Activity Verification Log".

All controlled drug discrepancies must be resolved before nurses on the shift leave. If the reason for the discrepancy is unknown the pharmacy and the CSM, Nursing Director, or ADON must be notified. An "off-going" nurse checks the Pyxis screen for discrepancies at the end of shift. The discrepancy log is signed by the "off-going" nurse indicating all discrepancies are resolved.

Drugs stocked in Pyxis will be removed and replaced by Pharmacy as needed. Controlled drugs returned to the pharmacy by pneumatic tube must be returned by the secured transaction.

6. NARCOTIC AND PCA KEYS:

Nursing units without Pyxis may have a maximum of 5 sets of keys to include a key for each lock on the Narcotic cabinet and a PCA key. Each set of keys will be numbered. The on-coming nurse who counts narcotics will account for keys. Refer to Department wide Guideline BB.

If a set of keys is unaccounted for or is taken home, the nurse must notify the CSM or the ADON, who will notify the CSM. It is then the responsibility of the ADON or CSM to determine if Physical Plant needs to change the locks on the Narcotic box and supply the appropriate sets of new keys. Pharmacy will no longer keep back-up keys for the Narcotic cabinet. A Variance Report will be completed.

 

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