Internal Audit Department Controlled Substance

OrientationErnest Thomas

Controlled Substance Investigator

792-4199 or Pager 11283Available by pager 24/7

Course ObjectivesWe 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.

Internal AuditOne of Internal Audit’s responsibilities includes

review of controlled drugs used in:

• Patient units,

• Hospital pharmacies,

• Clinics, and

• Research areas.

This duty is primarily performed by the

Controlled Substance Investigator

Know the Laws and Regulations For Your Discipline

• SC Code of Laws Section 40-33-110 [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 nursing

Know MUHA Policy Concerning Controlled Drugs

• MUHA Policy C-168 - Management of Automated Dispensing Machines

AcuDosePROTECT 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.

When You May Waste Controlled Substances

SC Code of Regulations 61-4-911: 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 40-33-110. 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

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.

Two Steps to a Waste

A waste is complete when two licensed individuals:1. Dispose of a medication in a manner in which it

is rendered unusable or irretrievable (wash down sink, dispose of in Sharps container, etc.) AND

2. Record 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.

When You May NOT Waste Controlled Substances

SC Code of Regulations 61-4-911:• 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 792-

1204 or email it to internalaudit@musc.edu. Lock the drug and the original of the form in the narcotics box.

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 emailed to internalaudit@musc.edu.

This form is available:• On each unit,• On the MUHA Forms directory:

http://academicdepartments.musc.edu/internalaudit/forms/CS%20Discrepancy%20Form.pdf,

• On the Internal Audit webpage: http://academicdepartments.musc.edu/internalaudit/controlled_substances/Forms.

Common Errors• Wastages – 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 the physician 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 Waste

All of these wastes should be documented in AcuDose

When You MAY NOT Waste

Contaminated controlled substances should be reported to Internal Audit

on a Controlled Substance Discrepancy

Report

A partial dose is ordered The medication is CONTAMINATED:• Broken seal or Tamp-R-Tel• Crushed or dropped tablet• Spilled liquid medication (save what

you clean it up with!)

The patient refuses the medication after it is prepared

The order is discontinued after the medication is prepared

Blood is aspirated into the syringe

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:1. 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

Diversion Happens Here

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.http://www.nursetogether.com/nurses-and-substance-abuse

You Are Responsible for ReportingDrug Diversions

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.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265282/

• Drug Abuse and Diversion are serious problems.

• SC Code of Laws, Section 44-33-110. 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.

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.

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.

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.

MUSC/MUHA Employee Assistance Program

(EAP)This confidential benefit is available to help you deal with:• Personal and family problems such as:

– Relationship issues– Divorce– Drug and alcohol dependency– Financial

• Work related problems such as– Absenteeism– Chronic tardiness– Poor morale

Call 792-2848 or visit the website at www.musc.edu/eap

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 mental illness.

The program ensures that impaired professionals receive the help they need at the earliest point possible. Call 1-877-349-2094 or visit their website at http://scrpp.org/

Contact Information Internal Audit Department

45 Bee Street843-792-4561

Ernest ThomasControlled Substance Investigator843-792-4199Pager ID 11283Alternate Pager ID 12540

Available by pager 24/7