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Controlled Substance Inspection Program

Controlled Substance Inspection Program. Training. Program Objective. Outline the role of the inspector & the nurse in the review and management of controlled substances. Why have this program?. Standard of Nursing Practice Professional accountability Ethical responsibility

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Controlled Substance Inspection Program

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  1. Controlled Substance Inspection Program Training

  2. Program Objective • Outline the role of the inspector & the nurse in the review and management of controlled substances

  3. Why have this program? • Standard of Nursing Practice • Professional accountability • Ethical responsibility • Legal accountability • Inspection of Controlled Substances required by VA CO • Audited by the Inspector General • **Because it is good medicine for our patients and our responsibility to nursing service, the organization, community, the profession, and VHA.

  4. Inspectors • Appointed for three years • Has formal training & certification • Alternate Inspector; Used if assigned inspector is not available • Responsible for a monthly assigned areas

  5. Inspectors • May not have involvement in drug procurement, prescribing, dispensing or administration of drugs • Conducts monthly, random, and unannounced inspections ensuring the element of surprise • Unannounced to both the unit andPharmacy • Must be on random days of month • Must be completed the same day started(can be suspended and restarted in case of an emergency).

  6. Inventory Audits • Controlled Substances are dispensed from Pharmacy to: • Pyxis – Automated Dispensing Machine • Green Sheet – Only in Research areas & Nuclear Medicine

  7. Procedure • A complete physical count is done on the first month of each quarter • (January, April, July, October) • A partial random physical count is done during the other months (February, March, May, June, August, September, November, December)

  8. Procedure A minimum of 2 people will be present and witness each inspection “The Buddy Rule” • Inspector • Charge representative of the unit • (usually the nurse manager or charge nurse) • Pharmacy inspections require the Chief of • Pharmacy or designee

  9. Procedure • Inspector: • Observes designated nurse (RN or LPN) performing inventory • Verifies the inventory count • Checks expiration dates for expired medications. • Weighs all unsealed powders • Measures all unsealed liquids with a volumetric cylinder • Reports waste • *The inspector is not to open any • sealed (by manufacturer) packages • of controlled substances for actual • count unless there appears to be • evidence of tampering

  10. Discrepancies • All discrepancies should be documented on the Controlled Substance Inspection Form. 1. A Controlled Substance Discrepancy Report is completed in SharePoint by the Inspector • 2. The discrepancy The discrepancy is reported to Pharmacy Manager, Unit Nurse Manager and Controlled Substance

  11. Nurse’s Role • Accurate counts • Timely entries • Follow-up with discrepancies • Being available for the inspection • Observing/witnessing all waste • Expressing concerns to nurse manager/supervisor on any suspicions (staff behavior changes, consistent errors etc.)

  12. Questions? Thank You

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