UT-Harris County Psychiatric Center

Nursing Procedures

 

Controlled Substance Audit

Nursing

Harris County Psychiatric Center: Office Administration

A controlled substance audit is the inventory and reconciliation of narcotics (Class II, III, IV, and V) stored on the Nursing Units for administering to patients

controlled substance, medication audit, discrepancies

The University of Texas Health Science Center at Houston

 

 

Definition

Date of Last Review 6/08

A controlled substance audit is the inventory and reconciliation of narcotics (Class II, III, IV, and V) stored on the Nursing Units for administering to patients.

 

Federal requirements

Below lists federal guidelines that are required by law:

·   All controlled substances require a physician order prior to administration to patients

·   Special documentation is required from Licensed nursing personnel

·   A controlled substance audit is to be conducted at shift change on the Controlled Substance Audit form

·   All controlled substances are kept under lock and key with the key in the licensed nurse’s possession at all times

·   The medication refrigerator is to be locked at all times

·   The following information is documented for each dose of narcotic administered to a patient:

–  Patient’s full name

–  Doctor

–  Dose given

–  Amount wasted (if any)

–  Signature and profession of the person administering the dose

–  A witness signature for any waste

Note:  The patient number is not required by law, it is used for billing purposes.

 

Audit process

The following are the steps in the audit process and the actions to be taken by nursing staff:

 

Step

Action

1

Shift counts are conducted by the on-coming nurse and the off-going nurse to verify:

·   The inventory of controlled substances

·   Accuracy of the documented count

·   Release the off-going nurse of the responsibility for controlled substances

2

The on-coming nurse verifies that the shift count is accurate and by so doing accepts full responsibility for all doses remaining.

3

The shift count is conducted with the off-going nurse visually inspecting both the audit sheet and the controlled substance being counted by the on-coming nurse.

Note:  This assures that the nurse only signs for what is actually in her/his possession.

4

Until the off-going nurse signs, she/he has not been released from the responsibility of controlled substances which she/he accepted at the beginning of the shift when signing as the on-coming nurse.

Note:  Shift counts are not considered complete until all information is completely filled in on the audit sheet.

5

Controlled substance waste requires two signatures, the person responsible for the waste and the witness.  The nurse witness must actually witness the waste.

6

All narcotic discrepancies in the controlled substance audit must be resolved at the time discovered and must be documented on the M.A.R. Discrepancy Report form. All nurses must remain on the unit until resolution occurs.

Be advised:  Licensed nurses should never accept a shift count that is inaccurate or incomplete (i.e. audit sheets with missing information that is required by law.)

7

Failing to adhere to this procedure may result in disciplinary action up to and including termination.

 

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