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

• Practitioners will immediately notify the Department of Pharmacy of the loss, destruction,
theft or unauthorized use of any controlled substance.
DAILY INVENTORY
• Change in shift inventories must be performed on all controlled substances each day and
recorded on the inventory control form.
• The inventory must be performed by two licensed individuals (nurse, physician, dentist or
pharmacist) unless the location has received exempt status by the Unified Director of
Pharmacy and sign the inventory control form.
• In patient care areas (i.e., outpatient sites, clinics, and special procedures rooms) where there
is only one nurse or no nurse, the physician(s) or dentist(s) is responsible for the maintenance
of controlled substances and adherence to all policies and procedures.
• In areas that are open for one shift (i.e.,9AM to 5PM) the inventory must be performed by
two licensed individuals and at the open and close of business. The time of the inventory
must be recorded on the inventory record. If the area (clinic, office, procedure room) is
closed on a particular day (Saturday, Sunday or holidays) the word "closed" must be written
on the inventory control form for that date.
• Those areas that have received exempt status by the Unified Director of Pharmacy will have
a controlled drug inventory performed at the open and close of business by one licensed
practitioner and indicate the word “self” in the appropriate space.
• Areas that utilize automated point-of-use dispensing technology are exempt from performing
the change of shift inventory daily. The count must be performed at least once a week on a
designated day.
RECORD KEEPING AND DOCUMENTATION
A separate record will be maintained of the administration of controlled substances indicating the
date and hour of administration, patient's full name (last and first), name and quantity, the
balance on hand after such administration, signature of person administering and name of the
prescriber.
REQUESTING CONTROLLED SUBSTANCES FROM THE PHARMACY BY HOUSE
STAFF
Controlled substances may be picked up from the Pharmacy in cases of emergency by house
staff provided a valid medication order has been written and the patient care area does not stock
the item. Controlled substances will be dispensed to the house staff personnel provided a
Montefiore Medical Center identification badge is shown. Identification badges from other
institutions are not acceptable. Once the proper requirements are confirmed, only one dose of
the controlled substance will be dispensed. The house staff personnel are responsible for
documenting the use and waste of the controlled substance on the disposition form and must
return the form back to the Pharmacy immediately upon completion of the emergency. Any
unused and sealed controlled substance must be returned back to the Pharmacy or given to the
nurse-in-charge in the care area for proper storage and inventory maintenance.
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