CONTROLLED SUBSTANCES HANDLING POLICIES

WEEKDAYS

• Narcotic Procedures: The satellite pharmacy located in the back hall of the operating room dispenses appropriate drugs and solutions for patients in the Operating Room and Recovery Room areas.

The checkout policy for controlled substances use by Anesthesiology personnel is as follows:

• From 7:30 am to 11 pm narcotics to be used on patients will be obtained from the OR pharmacist directly.  In order to obtain controlled substances, you must complete a Controlled Substance Request Card.  Please note:  You must sign the card in order to receive controlled substances.  Your signature ultimately means that you agree that you received the medications that you requested.  Thus, PLEASE CHECK YOUR DRUG BAG PRIOR TO LEAVING THE PHARMACY AREA TO MAKE CERTAIN THAT YOU, IN FACT, ARE RECEIVING THE MEDICATIONS YOU REQUESTED.  You will be held responsible for what you requested, so please make sure that what you requested and what you received are the same.   Drugs administered to the patients are logged appropriately in the patient record. Unused drugs are returned to the pharmacist following the completion of each case. 

  

   

  • Narcotic use slips (picture above) must be completed accurately by the resident and returned with leftover narcotics after each case. (DO NOT DISCARD LEFTOVERS.) The cc's of narcotics used on each patient and recorded on the patient's chart, and the number of cc's returned must add up to the total checked out.
  • Narcotics should be signed out for a specific single patient rather than for a whole day's cases.
  • Syringes and ampoules of narcotics must NEVER be left on the anesthesia machine or cart after a case is completed.  In addition, controlled substances must NEVER be left out on the anesthesia cart when the anesthetist is not physically in attendance at that location.  They must be either taken with the anesthetist or locked in the cart.
•     Narcotics must not be exchanged among anesthesia personnel or between the ICU and the operating room.  Personnel permanently relieving other residents or CRNA/AA must bring their own supply of any controlled substances that they anticipate needing.  (This policy does NOT apply to breaks of any type where the person being relieved is expected to return to the case.) The person being relieved should return all unused controlled substances that they signed out at the beginning of the case to the pharmacy, accounting for usage as described above.  This policy DOES APPLY to all drugs administered by infusion as well.  For example, if a patient is being managed with an infusion of fentanyl, the anesthetist leaving the case should take ALL unused medications with him / her including whatever is left in the infusion.  The new anesthetist may then choose to start a new infusion of fentanyl if he /she desires to do so.  In addition, if a patient is being sedated or given analgesia by infusion in the ICU, the practitioner should bring his / her own medications to continue sedation during transport.  The ICU infusions MUST be left in the ICU with the nurse caring for the patient.
• Between the hours of 7:30 am and 11 pm, all returned drugs should be delivered to the OR pharmacist.  Please again carefully verify that what you say you are returning is actually present in the returned bag.  After hours, controlled substances should be returned to the controlled substances lock box in the anesthesia workroom. 
• If you drop a controlled substance and the vial shatters rendering the drug unusable, or if you accidentally waste any controlled substance, please have another person who witnessed the event sign (signature AND printed name) your drug use card indicating a witnessed drug wastage. 
• If you dilute a controlled substance for use during a case, please be sure to label the syringe accordingly with the correct concentration.

• Between 11:00 pm and 7:30 am and on weekends, follow the After Hours Controlled Substances Procedures. 

 

AFTER HOURS CONTROLLED SUBSTANCE PROCEDURES

Effective August 8, 2006, the narcotic lock box in the Anesthesia Workroom will no longer be used to obtain controlled substances for use in after hours cases.  Instead, controlled substances will be dispensed from a OmniCell Cabinet located centrally in the Operating Room.  Please carefully read and follow the procedures listed below to obtain controlled substances after hours. 

The cabinet will be in service from:

11:00pm-7:00am Monday through Thursday

11:00pm Friday thru 7:00am Monday

To access the cabinet for the first time, please use your Shands Portal username. You will then be prompted to create a password.  The pharmacy has set parameters on your passwords so they should never expire until you complete your residency training. 

Controlled substances should be removed under patients name. In the event of a trauma patient, there will be generic trauma pack of medications to sign out. 

Case cards (same as the current narcotic cards - see picture below) will be located on the side of the cabinet.  All narcotics removed must be accounted for on the case cards as you do currently (see Narcotics Policies).  Unused controlled substances and all syringes to be wasted should be placed in plastic bags together with the case card and  deposited into the black safe in the anesthesia workroom after each case is completed (same as you currently do). 

 

*Prior to a MOLE/Call shift, please verify that your login and passwords are functional by logging into the cabinet the day prior to beginning a shift. 

In the event your forget your password while you are on a call or mole shift, please see the recovery room charge nurse for a temporary ID and e-mail Suremed Requests (suremed@shands.ufl.edu) to reset your password.

***Cabinet difficulties - contact the pharmacy (5-0069)***

CASE CARDS

WHAT HAPPENS IF POLICIES ARE VIOLATED OR DRUGS HANDLED INAPPROPRIATELY?

• Dropped or wasted narcotics - witnessed:  No follow-up is necessary.  If there are more than 5 incidences in a one month period with a given practitioner, the practitioner will receive an administrative note from the pharmacy admonishing him /her to be more careful.  A copy will be sent to the personnel file.  Please note, that in order to count as a witnessed wastage, the person witnessing the event must sign the narcotics card and print his / her name on the card verifying that the drugs were indeed dropped or wasted.
• Dropped narcotics - unwitnessed:  If there are > 3 episodes in a one-month period, the practitioner will receive an administrative note and all drug returns will be refracted for accuracy for a 30-day period.  The pharmacist will pull all the drug use cards for this practitioner and compare cards with the anesthesia record.  This practitioner will be reviewed weekly by the Departmental Narcotics Control Officer and the program director.
• Narcotic use cards not returned within 24 hours or only after pharmacy request:  The practitioner will receive an administrative note from the pharmacy with a copy to his/ her personnel file.
• Narcotics left unattended in the OR (or elsewhere) and returned by someone else:  This is considered a VERY serious offense.  Consequences for this behavior will be:
  • Strongly worded administrative letter to personnel file after first offense
  • Administrative probation for 3-months after the second offense.  If during the probation period, narcotics are left unattended again, the offense will constitute grounds for dismissal from the Department.  After a successful probation, consequences of further violations will be at the discretion of the program director.
• Narcotics lost:  This is also considered a very serious offense and will be treated similarly to narcotics left unattended (first offense - strongly worded administrative note; 2nd offense - administrative probation).  In addition, even first time violators will have all drug returns refracted for a period of 30 days.  Patient charts and drug use cards will be pulled and regularly reviewed during that time period.
• Incorrect or incomplete documentation on anesthesia record or drug use cards:  Practioner will be directly counseled by the program director.  Continued violations may result in administrative probation as described above for narcotics left unattended.
• Incorrect drug refraction on returned medications:  Drug returns from all practitioners are randomly refracted to verify returned drug content.  Thus, it is extremely important to accurately label all controlled substances, particularly if the drug is diluted (as may occur in a pediatric case, for example).
  • With the first violation, the practitioner will receive an administrative note with a copy to their file.  All returned syringes will be refracted for that practitioner for the next 30 days.  All anesthesia records and drug use cards will be examined for discrepancies, and results reviewed weekly by the narcotics control officer and the program director. 

PRESCRIPTION WRITING POLICIES

As part of your job here, you will be provided with prescription pads for your use, primarily in the clinical base year rotations and in the Pain Clinic.  Please be aware that you MAY NOT write a prescription for anyone who does not have a documentable physician / patient relationship with you (i.e. a patient chart exists documenting this relationship).  This prohibition most especially includes your resident colleagues and any family members.  While the policy was written primarily to prevent abuse of controlled substances, the policy applies equally to antibiotics, antihistamines, or any other substance requiring a physician presciption.  If you or your family member need a prescription drug and do not have a physician here in Gainesville, please see the program director who will refer you or your family member in an expedited fashion to a physician appropriate to care for the medical problem requiring the prescription.  Remember, your signature on a prescription pad means you take personal responsibility for whatever is written on the prescription, and prescriptions can be altered.  Your license (either as a housestaff officer or as a Florida physician) could be in jeopardy from violation of this policy.

Document revised 3/10/2008.