1. Countable Controlled Substances
Medication Education Module 1
Countable Controlled Substances
****Trainer Preparation
For Trainer:
PowerPoint “Notes” pages
Responsibilities in Action (RIA) curriculum; can be downloaded at scroll down to "what would you like to do" and select View MAP training resources and curriculum, then select DDS MAP training resources; once there you will see MAP Curriculum and Adjunct Materials
For Staff:
PowerPoint handout
Print page 2 “Objectives” to test staff knowledge before & after the training (Use as your training documentation.)
Corresponding MAP Policies 10-2, 10-3, 10-4, 10-8
Shoulder to Shoulder Count Video available at
Countable controlled substances are sometimes referred to as narcotics. Tell staff what the pharmacy service you use does to “identify” the package of a countable substance so staff knows which are countable.

2. Objectives 1. Why count them so often? 2. Why the extra documentation?
3. Why the special packaging?
What I know about countable medication before the training: 1. 2. 3. 4.
What I learned about countable medication after the training:
4. Why the extra security?

3. Countable Substances Must be double key locked A lock within a lock
Keys must be carried by the staff assigned med administration duties for the shift
See Responsibilities in Action pages 70,71,155

4. Countable Substances Higher incidence of abuse or addiction
Count requirement
Each time keys change hands, 2 Certified staff count together
Documentation requiring 2 signatures
When beginning a new count sheet
Adding a refill onto a count sheet
Transferring from
bottom of old page/top of new
an old count book to a new count book
Disposal
The purpose of requiring 2 certified staff signatures is to decrease the opportunity for diversion (theft).
See Responsibilities in Action page 171.

5. Schedules In the Medication Administration Program (MAP)
Any prescription meds in
Schedules II-V are categorized as
Countable Controlled Substances
The federal government categorized prescription meds into “schedules” II- VI according to the meds potential for abuse or addiction.
Schedule I meds have the highest potential for abuse and currently have no accepted medical use in the United States; examples are heroin and LSD.
Meds categorized in schedules II-V are considered to have a greater potential for abuse than the schedule VI meds
In addition to keeping documentation of all prescription meds ordered and received, countable substances must be entered into and tracked in a Countable Controlled Substances book.
See Responsibilities in Action pages 33-35

6. Schedules
Schedule VI
All prescription meds which are not required to be counted
Examples
Penicillin
Dilantin
Schedule VI meds are not required to be added into a count book.
See Responsibilities in Action page 33.

7. Schedule VI
Although not required, DPH strongly recommends adding some specific meds to the count, such as
Fioricet
Gabapentin (Neurontin)
Fioricet is used to treat tension headaches.
Gabapentin (Neurontin) may be used for seizures and/or nerve pain.
See Responsibilities in Action page 34 ‘Call-out symbol’

8. Why Count and Record? Protect Safety of Individuals
Certified staff from being accused of mishandling or misusing
This slide is self explanatory.

9. Why Count and Record?
Assist Certified staff in adhering to laws, regulations and policies
If countable substances or prescriptions are taken by a Certified staff an investigation will follow with possible police involvement
This slide explains why it is so important to always follow the guidelines.

10. Tamper Resistant Packaging
Purpose
To minimize the chance that the medication inside is replaced with another
Blister packaging is the most common. Examples of other tamper resistant packing options are OPUS (cassettes) and Opti-pak (unit dose).
If you participate in “blister pack monitoring” [not a requirement] you could mention here that staff document, ONLY on the backside of the package, their initials, date and time each tablet is removed and that you monitor periodically to ensure all meds are given as ordered.
See Responsibilities in Action page 156

11. Tamper Resistant Packaging
Blister packs are an example of tamper resistant packaging

12. Liquid Countable Medication
Liquid countable medication must also be packaged in tamper resistant packaging; a liquid countable medication should never be packaged in a multi-dose bottle.

13. Security Access to the med storage area is limited
The Certified staff assigned med administration duties is the only staff allowed access to the med storage area
Knowledge of access to the duplicate or back up key is known only to an administrative staff.
See Responsibilities in Action page 71

14. Security-Inventory
The Certified staff assigned to give meds is responsible for the inventory (supply) during their assigned shift
Must
Count at beginning and end of shift
Keep key with Certified staff assigned as long as they are in program
See Responsibilities in Action pages

15. Security-Inventory
If there will be no Certified staff home during the day, the keys must be kept locked in the home
Realtor type combination locked box
Count must be done before placing keys in the locked box and after removing keys from the locked box
Only MAP Certified staff know the combination to the locked box.

16. Security-Inventory
Whenever there are 2 Certified staff available there must always be a 2 person count
Conducting a 2 person count once every 24 hours is an “exception” to MAP policy
If there is no one else available a single person count must be done
The count signature page must indicate it was a “single person count”
When the count signature page has a staff who has signed their name and written “single person count”, that means they were not working with another MAP Certified staff to witness that the count was correct.

17. Security-Inventory Due to staffing patterns
The “exception” becomes the “norm” when the typical staffing pattern is 1 Certified staff throughout a 24 hour period
A Supervisor will ensure that at least once every 24 hours 2 MAP Certified staff are available to conduct a 2 person count together
This is the only time it is permissible to count only once every 24 hours with 2 MAP Certified staff.
The ONLY time a single person count should be done is when there are no other MAP Certified staff on duty to count with.
In this case in between the 2 person count should be single person counts.

18. Security-Inventory
Only Certified staff who may be assigned to administer meds should know the locked box code
The combination should be changed when a Certified staff is no longer working at a site or staff is no longer Certified (such as did not pass recertification)
These are examples of how often the combination should be changed.

19. Security-Inventory
Whenever the Certified staff assignment to give meds changes
Keys are passed
A count must be done
This is how often a count should be done.

20. Security Count must be done
Shoulder to shoulder with the off-going Certified staff and the on-coming Certified staff
Countable meds must be counted every time the shift/staff changes, ideally with a staff coming on and another staff who is leaving. If that is not possible, count with another MAP Certified staff working on the same shift.
See Responsibilities in Action page 166

21. Security-Inventory On-coming Certified staff has blister packs
Off-going Certified staff has count book
Leads the count using the index
Consider actually counting with a staff here to demonstrate.
Counting must be done using the index.
See page 166 in the Responsibilitis in Action curriculum for the step by step Shoulder to Shoulder count procedure.
Shoulder to Shoulder count video available at and at

22. Security-Inventory During the count process
Both staff look at blister pack and count book
Full legal signatures on shift count verification page
When documenting on the count signature sheet be sure to document in ‘real time’; do not ‘round’ to the closet hour.

23. Count Book Must have a binding
an index, count sheets and count signature sheets
preprinted page numbers
pages that cannot be removed
The next 3 slides cover the basics of the count book itself.
Each count book is “numbered” somewhere in the front and also must list the site address
If the pages become loose staff should notify a Supervisor so that another book can be obtained as quickly as possible.
See Responsibilities in Action page 159

24. Index Must be kept accurate and up to date
Assigned Certified staff can add a countable substance into the index
The Site Supervisor (or designated back up) is responsible for removing a countable substance from the index if/when needed
Examples of when the supervisor would sign in index as removing from count would be when a med is discontinued and disposed; a supervisor’s signature in this column means there is no longer a med to count.
A row in the count book index may be highlighted to indicate that either the med is no longer on count or has been moved to the next available index row, explain this process to staff if needed.
Lines on an index or pages of an index should NEVER be skipped.
See Responsibilities in Action pages

25. Security-Inventory
When entering a countable substance in the book or transferring to a new page the assigned Certified staff should complete the Heading section of the next available page
Do not skip pages
The staff giving meds who uses the last line on a count sheet is the one who transfers the information to the next available count sheet and updates the index.

26. Sample Index Page
The index page at the beginning of a count book identifies the pages that are currently in use. It must be kept accurate and up to date. According to this index, there are 3 count sheet pages currently in use.
Looking at this index, you know Sarah Brown’s Phenobarbital is no longer in the doubled locked area to count because Karen Mason (Supervisor) signed as removing it from the count. If the med was discontinued, it would have stayed on count and double locked until disposed of. Only after its disposal (following the guidelines) would a supervisor sign as ”Responsible for Removing Medication from Count”.
Mike Stone has Ativan 1mg tabs to be counted on p. 5 (because p. 2 became full.) The index must be updated when transferring information from an old count page to a new count page.
When the 4 boxes next to Joseph Smith’s Ativan were full, the staff wrote “see below” with their initials to indicate his Ativan had started on a new row in the index. Joseph Smith’s Ativan 0.5mg is currently found on page 11.
William Mitchell has Percocet to be counted on page 8.

27. Count Sheet Scenario 1 Page transfer
Look at the first yr entry – This is an example of when page 10 of the count book was ”full”, the information was transferred onto the next available page. Karen and Lisa’s signature would be at the bottom of the ”full” page [page 10] also.
12/20/yr 11:00 am entry – this is an example of meds that had been re-ordered and the refill blister package is added to the existing supply. When added, the MAP Certified staff was working alone.
12/20/yr 3:00 pm entry - Hours later when the second MAP Certified staff came in, that staff verified the amount received from the pharmacy and documented.

28. Count Sheet Scenario 2
Page 11
Page transfer
Scenario 2 demonstrates when the count is correct in a blister pack but the math documentation in the count book is incorrect.
A supervisor will look at the incorrect documentation and counsel the staff who subtracted incorrectly to be more cautious.
12/20/yr 7am Math on 12/19/yr 8pm entry is incorrect. Karen Mason, Supervisor notified. Correct count is 6 left Reggie Newton

29. Count Sheet Scenario 3
Page 11
Page transfer
Scenario 3 is an example of the count being correct but the staff forgot to document the med when it was removed from the package.
A “late entry” should be documented by the staff who gave the med but forgot to document.
No spaces should be skipped for the staff to “go back” and subtract later.
12/20/yr 7:45pm Morning dose not subtracted when removed. K. Mason notified. Lisa Long
12/21/yr 6am Late entry On 12/20/yr 8am med was given and not documented at that time. Reggie Newton

30. Count Sheet Scenario 4 Page transfer
Scenario 4 are examples of how to correct documentation errors in the count book.
Lisa wrote small enough and neat enough to be able to correct on the same line.
Reggie’s writing is bigger and he decided to mark a single line, error and initial through the entire row and rewrite the information.
Error LL
Error RN

31. Count Signature Sheets
The last section of the count book contains the count signature sheets. Countable controlled medications must be counted with 2 Certified staff every time the medication storage keys change hands including when placed into or taken out of the storage combination lock box. If/when counting alone , document in the space near your name ‘single person count’.
Document in real time; do not ‘round’ to nearest hour.

32. Questions
With countable meds, it is important to always write a story in the count book (no matter how many lines it takes) to explain anything out of the ordinary that happens.

33. Resources MAP Curriculum- Responsibilities in Action
MAP Policy Manual