Medical Staff House Staff Orientation Manual - Montefiore Medical ...

VERBAL, TELEPHONE, OR FAXED CONTROLLED SUBSTANCE ORDERS
• Are allowed for inpatients in emergency situations only. An emergency is defined as the
immediate administration of the controlled substance is needed for proper treatment and no
alternative treatment is available.
• Are permitted only if it is not possible for the practitioner to provide a written order before
the needed administration of the drug.
• Can only be provided by an attending physician or fellow
• May be continued by house staff, but is restricted to a one time dose
• Must be signed by the physician within 24 hours.
LOSS OR DISCREPANCY OF A CONTROLLED SUBSTANCE
A loss of a controlled substance, including an unresolved discrepancy must be reported to the
Security Department, Department of Pharmacy and chair or manager of the department. An
investigation of the incident and written report, including a list of all individuals who have had
access to controlled substances and their license numbers, must be submitted to the Department
of Pharmacy. The Department of Pharmacy will complete the Report Form for Loss of
Controlled Substances and submit to the New York State Department of Health Bureau of
Controlled Substances Narcotic Enforcement Unit.
DEA NUMBERS
Under the Federal Controlled Substances Act, a practitioner is required to register with the Drug
Enforcement Agency (DEA) in order to prescribe and administer controlled substances. Certain
house staff physicians are not eligible for a federal registration number (interns and certain
residents). Therefore, provisions have been made under federal law to assign a temporary
number (hospital number plus an assigned suffix number), which authorizes the practitioner to
prescribe controlled drugs within the medical center. Interns and residents rotating at Montefiore
from other training programs are not eligible for a temporary Montefiore DEA number and
suffix.
OUT-PATIENT PRESCRIPTION WRITING
• New York State law requires all prescriptions to have a stamp/imprint in addition to the
prescriber's signature.
• The complete DEA number and suffix must be written on the prescription.
• The assigned number can only be used while employed at the medical center and on
prescriptions written for Montefiore patients.
STORAGE AND SECURITY
Controlled substances must be stored in a stationary, secured cabinet with double lock and key to
ensure adequate safeguards and security measures are undertaken to prevent against the loss,
destruction, theft or unauthorized access. Automated point-of-use
technology (Pyxis Medstation System) is an acceptable alternative to a cabinet.
• The cabinet will have inner and outer doors with separate keys. Spring locks or combination
locks are not acceptable.
• When not in use, the keys to the narcotic cabinet must be stored in a secured manner (e.g.,
locked drawer and unavailable to unauthorized personnel).
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