In the Long-Term Care industry, we are surrounded by opioids and other controlled substances. It is easy to become lax with regulations and ignore procedures. It is important to maintain a “heathy paranoia” and be vigilant when handling controlled substances. If, and when a discrepancy or narcotic diversion occurs, you want to ensure that you have been documenting and counting properly.
Following these procedures, along with any others established by your company, to help ensure that discrepancies are discovered timely, controlled substances are given correctly, and diversion is less likely to occur.
a.Controlled substances often have their own delivery slip and are kept separate from the rest of the medications and supplies coming from the contract pharmacy. Make sure the quantities and resident info match the delivery slips.
b. Lock up controlled medications, under double lock, as soon as possible.
c. Controlled substances should be entered into the narcotic record right away and signed off by another authorized person (RN, LPN, med tech).
2. Filling out the Individual Narcotic Record:
a. Records need to be kept for 8 years. To help aid in tracking, number your narcotic books. Since communities often have multiple books in use at once, we recommend that you number the book using the station name and date that the book was started. Example: Book “2 South 2/5/19”
b. If your pharmacy provides them, use the “book” sticker to label the page, enter in the quantity and initial with a witness.
c. If no sticker is available, fill out ALL sections of the page. Do not write “See MAR” or “See Directions” under the ‘directions’ sections. Opioids are one of the top three drugs that lead to adverse drug events. To help ensure they are given according to the order, fill in the current directions. When the directions change, transfer the drug to the new page with the new directions.
d. Do not use the refill sticker to label the page. If the sticker is missing, people will assume the drug has been requested from the pharmacy even though it has not. This can lead to a delay in therapy or missed meds.
e. Enter in the pages that medications are transfer ‘to’ and ‘from’.
f. Enter in whole tablets under quantity so that the delivery slip, pharmacy records and label quantities all match the book. For example, if the bingo card is full of half tabs, the quantity is 15, or 30 half tabs. It is best to write out “half tabs” vs “1/2”.
g. Don’t use initials to sign for a drug. The inventory record asks for a “nurse’s/med tech’s signature”, not an initial.
h. Enter in the actual time that you removed the drug, not the prescribed time.
i. Fill out the book right away. It is an inventory of what is in the cart, not whether the resident took the medications.
j. If a drug has been removed from the EKit and is not single use, it still needs to have a pharmacy label affixed to the bottle/bag/container. If your pharmacy provides an EKit label, make sure you use it to label the drug and not the page in the narcotic book.
k. If you make an error, simple draw a line through it, write “error” and initial.
3. Change of shift:
a. The book needs to dictate the count. If you just grab a card and look for the page number, you will not detect missing medications.
b. Check each other’s numbers
c. Make sure the Rx number on the label matches the book. There may be multiple cards for a resident. The only unique identifier is the Rx number.
d. Sign the change of shift log. Do not pre-sign.
e. Don’t forget to complete a change of shift for the EKit medications. It is okay to only do this once a day but follow your company policy. Resolve any discrepancies right away.
4. Other notes:
a. Do not tape the pill back into the package. They need to be destroyed
b. If the foil backing tears, the drug is considered contaminated and should be destroyed.
c. Clean counting trays after each use.
d. Clean oral syringes used for liquid narcotics after each use.
e. Try to DC’d medications (if appropriate) that have not been used within 60 days. Don’t wait for them to expire.
f. Store liquid lorazepam in the fridge under double lock. It is only good for 90 days once opened.
g. Finish with one bingo card before moving on to the next one.
References: FTag 755; FTag 759: FTag 760; FTag 761; RCW 74.42.260; WAC 388-97-1300; WAC 246-865-050; WAC 246-865-060; WAC 246-869-210; WAC 246-865-030; Title 21 C.F.R 290.10; 1300.03; 1301.27; 1301.75; 1304.04; 1304.22; 1305; 1306.05; 1306.11-13; 1306.21-22; 1311; October 6, 201