Presentation on theme: "Internal Audit Department Controlled Substance Orientation"— Presentation transcript:
1 Internal Audit Department Controlled Substance Orientation Ernest ThomasControlled Substance Investigatoror Pager 11283Available by pager 24/7
2 Course Objectives We will review: The role of the Internal Audit Department and the Controlled Substance Investigator at MUSC.The responsibilities of the professional with access to controlled substances at MUSC.Wastage and discrepancy policies for controlled substances at MUSC.Common errors.The proper storage and disposition of patient prescription medications.Your responsibility to report drug diversions.Characteristics of individuals who divert controlled substances.
3 Controlled Substance Investigator Internal AuditOne of Internal Audit’s responsibilities includes review of controlled drugs used in:Patient units,Hospital pharmacies,Clinics, andResearch areas.This duty is primarily performed by theControlled Substance Investigator
4 Know the Laws and Regulations For Your Discipline SC Code of Laws Section [Nurse Practice Act]. Grounds for discipline of licensees.violated a federal, state, or local law involving alcohol or drugs… conviction is not required to prove misconduct under this item.obtained, possessed, administered, or furnished prescription drugs to a person including, but not limited to, one's self, except as directed by a person authorized by law to prescribe drugs;engaged in the practice of nursing when judgment or physical ability is impaired by alcohol, drugs, or controlled substances or has declined or been unsuccessful in accomplishing rehabilitation;failed to make or keep accurate, intelligible entries in records as required by law, policy, or standards for the practice of nursing4
5 Know MUHA Policy Concerning Controlled Drugs MUHA Policy C Management of Automated Dispensing Machines
6 AcuDose PROTECT YOURSELF! Run and review AcuDose activity reports for your patients and yourself at the end of each shift.Run a discrepancy report and make sure all outstanding problems are resolved before you leave the unit.Never give out your ID and password.You are legally accountable for all transactions that occur under your ID and password.
7 When You May Waste Controlled Substances SC Code of Regulations :A partial dose is ordered; waste the unused portion.The patient refuses the medication after it is prepared; waste the entire dose.The practitioner discontinues the order after the medication is prepared; waste the entire dose.Blood is aspirated into the syringe; waste the dose.EVERY WASTAGE MUST BE PERFORMED AND WITNESSED BY LICENSED PERSONNEL.SC Code of Laws Grounds for discipline of licensees.- indicated the witnessing of wastage of narcotics or controlled substances on record when the wastage was not witnessed or failed to obtain a witness to the wastage of narcotics or controlled substances
8 Wasting Controlled Substances – Are You Sure? Per policy C-168, the wastage must be performed at the time the dose is prepared, or as soon as possible after the administration of the dose. A witness should be reasonably sure the drug that is wasted is the drug he/she is attesting to. Delays in wasting drugs may create doubt as to the identity of the drug being wasted.
9 Two Steps to a WasteA waste is complete when two licensed individuals:Dispose of a medication in a manner in which it is rendered unusable or irretrievable (wash down sink, dispose of in Sharps container, etc.) ANDRecord the waste in an patient record system (AcuDose, the medical record, etc.)A witness to a wastage should ALWAYS WATCH the disposal of the medication.A wastage must be performed at the time the dose is prepared, or as soon as possible after the administration of the dose.
10 When You May NOT Waste Controlled Substances SC Code of Regulations :Broken seal or Tamp-R-Tel.Crushed or dropped tablet.Spilled liquid medication. Mop up the liquid with 4x4 gauze, place the gauze in a plastic bag, and store the bag safely.When these situations occur, complete aControlled Substance Discrepancy Report and fax it to or it to Lock the drug and the original of the form in the narcotics box.
11 Controlled Substance Discrepancy Report Reportable controlled substance discrepancies must be documented on Controlled Substance Discrepancy Report form and faxed to the Internal Audit Department (2-1204) or ed toThis form is available:On each unit,On the MUHA Forms directory:On the Internal Audit webpage:
12 Common ErrorsWastages – Know when you LEGALLY may and may not waste controlled substances.A transaction is incomplete – A trained individual should be able to trace a transaction involving a controlled substance from thephysician order dispense waste (if necessary) administration. One should be able to account for the entire amount dispensed. Omitting steps causes the transaction to be incomplete and may jeopardize patient safety or cause compliance issues.When You MAY WasteAll of these wastes should be documented in AcuDoseWhen You MAY NOT WasteContaminated controlled substances should be reported to Internal Audit on aControlled Substance Discrepancy ReportA partial dose is orderedThe medication is CONTAMINATED:Broken seal or Tamp-R-TelCrushed or dropped tabletSpilled liquid medication (save what you clean it up with!)The patient refuses the medication after it is preparedThe order is discontinued after the medication is preparedBlood is aspirated into the syringe
13 Storage and Disposition of Patient Prescription Medications When a patient presents with medications from home:Send the medications home with a member of the patient’s family.If this is not possible:Inventory the medications with a witness, seal the medications in a security bag and store the medications in the locked narcotics cabinet.2. Document the inventory and location of the drugs in patient’s database or chart.3. Return medications to patient upon discharge. Note in the patient’s record that the medications were returned.4. If the medications are not returned to the patient upon discharge, send a 30-day notification letter.5. After the 30-days has elapsed, call Internal Audit for destruction of controlled substances.Sample 30-day notification letter
14 Diversion Happens Here First impressions are usually formed within the first 2 to 3 minutes of a presentation. The audience wants to like you and will give you a few minutes to engage them – don’t miss the opportunity!It has been estimated that 10 to 15 percent of all nurses in the United States are addicted to some type of illegal or controlled substance.14
15 You Are Responsible for Reporting Drug Diversions Drug Abuse and Diversion are serious problems.SC Code of Laws, Section Grounds for discipline of licensees.Failed to report incompetent or unprofessional practice of a licensed nurse to the appropriate authorities, including the board.Nurses have an ethical duty to protect patients, colleagues, the profession, and the community.Source: Nurse Drug Diversion and Nursing Leader's Responsibilities: Legal, Regulatory, Ethical, Humanistic, and Practical Considerations.JONA's Healthcare Law, Ethics, & Regulation. 13(1):13-16, January/March 2011.If you suspect that someone is diverting drugs, DO NOT intervene on your own.Contact your Nurse Manager and the Controlled Substance Investigator in the Internal Audit Department.Given the increasingly stressful environment due to manpower shortages in the healthcare system in general, substance induced impairment among some healthcare professions is anticipated to grow.
16 Possible Signs of Impairment Personality change;Patient and staff complaints about quality of care, attitude, or behavior;Interpersonal relations with colleagues, staff and patients suffer;Wearing long sleeves when inappropriate;Deteriorating personal appearance;Increasing personal and professional isolation.Volunteering to care for patients on pain medications;Heavy "wastage" of drugs;Sloppy recordkeeping or deterioration quality of recordkeeping;Insistence on personal administration of injected narcotics to patients;Progressive deterioration in personal appearance and hygiene;Work absenteeism;Frequent disappearances from the work site;Excessive amounts of time spent near a drug supply;Unreliability;Variations in work performance;Poor judgment;Confusion, memory loss, and difficulty concentrating;Nurses who are chemically dependent may be successful at disguising dependency issues because they are often stellar employees, popular, respected, and bright.Source: Nurse Drug Diversion and Nursing Leader's Responsibilities: Legal, Regulatory, Ethical, Humanistic, and Practical Considerations.JONA's Healthcare Law, Ethics, & Regulation. 13(1):13-16, January/March 2011.
17 Possible Signs of Diversion Patient complaints about poor pain control;Inaccurate narcotics counts;Offers to administer medications to patients the nurse is not assigned to;Frequent delays between administration and wasting drugs;Frequent or unexplained disappearance from the unit.The ANA estimates approximately 6% to 8% of nurses are practicing while impaired.Source: Nurse Drug Diversion and Nursing Leader's Responsibilities: Legal, Regulatory, Ethical, Humanistic, and Practical Considerations.JONA's Healthcare Law, Ethics, & Regulation. 13(1):13-16, January/March 2011.
18 MUSC/MUHA Employee Assistance Program (EAP) This confidential benefit is available to help you deal with:Personal and family problems such as:Relationship issuesDivorceDrug and alcohol dependencyFinancialWork related problems such asAbsenteeismChronic tardinessPoor moraleCall or visit the website at
19 S.C. Recovering Professionals Program (RPP) RPP is a state-wide confidential referral and monitoring programfor licensees of the South Carolina Boards of Medical Examiners, Nursing, Pharmacy, Dentistry, Podiatry Examiners, Chiropractors, Counselors, Occupational Therapy, Optometry, Physical Therapy, Psychology, Social Workers, Speech Therapy & Audiology, and Veterinary.It is for professional who are experiencing problems related to:alcohol and/or other drug abuse or dependence,or from a dual diagnosis of addiction and mentalillness.The program ensures that impaired professionals receive the help theyneed at the earliest point possible. Call or visit their website at
20 Contact InformationInternal Audit Department45 Bee StreetErnest ThomasControlled Substance InvestigatorPager ID 11283Alternate Pager ID 12540Available by pager 24/7