1.     The hospital must comply with the Narcotic and Controlled Drug (NCD) regulations of the federal Controlled Drugs and Substances Act. NCDs in the hospital are those assigned by this Act as well as those designated by the Drugs and Therapeutics Committee.
2.     NCDs may only be dispensed or administered to a patient of the hospital upon a physicianís written order in the health record. Exception: a distraught relative of a patient may be administered a single dose of a sedating drug (non-narcotic) upon a written order in the patientís record as per policy 4.8.
3.     Physicians and staff may not obtain a NCD from the hospital for themselves or their office.
1.     All NCDs must be stored in a locked compartment or automated dispensing cabinet except refrigerated narcotic infusion bags.
2.     Keys for locked compartments must be carried by nursing unit personnel or stored in an approved lock box at all times. Areas with more than one narcotic key must account for all keys at the end of each shift and document this in the NCD Administration Record Book. Keys lost or removed from hospital premises require a lock and key replacement by Physical Plant personnel.
        NOTE: Keys to PCA pumps are not considered narcotic keys even though a narcotic may be infusing.
1.     All receivals and issues of NCDs on nursing units must be documented in the NCD Administration Record Book or in an automated dispensing system record. Issues must include the patient name, physician name, and dose.
2.     All wastage of NCDs must be signed by a witness after observing the wastage into the sharps container on the units.
3.     Counts must be performed once per shift by two nurses or perpetually in an automated system.  An
        incident report must be completed for any discrepancies not resolved prior to shift change.  A count
        variance of less than 5% for oral narcotic solutions can be corrected without completion of an incident
        report.  The Patient Services Manager is responsible for ensuring discrepancies are resolved and all
        required signatures are obtained in the NCD Administration Record   Book which must be returned to
        Pharmacy within 2 weeks of completion.
  •       In the automated system, a weekly cycle count is also performed for all narcotic and controlled drugs in each patient care area (except for those using Omnidispensers) as assigned by the Patient Care Manager/designate.  For areas with high patient turnover, once a day cycle count is recommended.
4.     For units not using an automated system, delivery of a NCD may be performed by a hospital porter if the drug is contained in a sealed bag with appropriate documentation. The porter is not required to remain on the unit while the nurse verifies the contents.