|NARCOTIC AND CONTROLLED DRUGS:
6.1 REGULATIONS, STORAGE AND DOCUMENTATION
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.
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.
and staff may not obtain a NCD from the hospital for themselves or
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
Keys lost or removed from hospital premises require a lock and key
replacement by Physical Plant personnel.
to PCA pumps are not considered narcotic keys even though a narcotic
may be infusing.
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,
All wastage of NCDs must be signed by a witness after observing the
wastage into the sharps container on the units.
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.