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HomeMy WebLinkAbout9000_05 Controlled Substances SOP 202305039000.05 Controlled Substances Standard Operating Procedure Implemented: March 2023 Revised: N/A Next Review: March 2025 This procedure is for internal use only and does not enlarge an employee’s civil liability in any way. The procedure should not be construed as creating a higher duty of care, in an evidentiary sense, with respect to third party civil claims against employees. A violation of this procedure, if proven, can only form the basis of a complaint by this department for non-judicial administrative action in accordance with the laws governing employee discipline. Related Policies: Applicable HI Statutes: I. PURPOSE To provide clear standardized instructions on how to properly account for all controlled substances utilized on Advanced Life Support (ALS) ambulances in the Hawaiʻi Fire Department (HFD). II. DEFINITIONS Controlled Substance: A drug or substance, or immediate precursor, included in schedule I, II, III, IV, or V of Part B under Subchapter I (Control and Enforcement) of Chapter 13 (Drug Abuse Prevention and Control) under DEA Title 21 (Food and Drugs). Drug Enforcement Administration (DEA): A United States federal law enforcement agency under the U.S. Department of Justice tasked with combating drug trafficking and distribution within the U.S. Narcotics Enforcement Division (NED): A Division of the State of Hawai’i’s Department of Public Safety that protects and promotes the health and safety of Hawaiʻi by enforcing controlled substance and regulated chemical laws and pursuing the appropriate use of pharmaceuticals. III. ACTIONS Ensure proper accountability, recordation, and administration of controlled substances. In order to use Schedule II-V Controlled Substances on an ALS ambulance, HFD is required by County, State, and Federal law to properly account for all medications. This Standard Operating Procedure (SOP) ensures that we are compliant with all laws and regulations set forth. IV. GUIDELINE: This SOP shall be broken down into four different categories to include the following: • Ordering of Controlled Substances • Recordation of Controlled Substances • Storage of Controlled Substances • Reporting Discrepancies of Controlled Substances V. PROCEDURES: A. Ordering of Controlled Substances: 9000.05 Controlled Substances Standard Operating Procedure Implemented: March 2023 Revised: N/A Next Review: March 2025 1. The Requisition Form for Controlled Drugs shall be filled out by the appropriate EMS Branch personnel once a request for replacement medications is received from a Fire Medical Specialist. 2. Medications are inspected by an EMS Branch personnel and then placed in a tamper evident plastic bag. It is then transferred in a lockable cash box under direct supervision by an EMS Branch personnel to the requesting on-duty Fire Medical Specialist. 3. Medications are to be inspected and inventoried by the on-duty Fire Medical Specialist once replacement medications are received. The completed Requisition Form for Controlled Drugs must be signed and dated confirming proper hand-off of medications. 4. The signed and dated Requisition Form for Controlled Drugs is to be returned to the EMS Branch for filing. B. Record Keeping of Controlled Substances: 1. The receiving Fire Medical Specialist shall log the additional amount of controlled substances received on the HFD Daily Controlled Medication Sign-Off Sheet. 2. During changeover, the off-going and on-duty Fire Medical Specialist MUST inspect and go over inventory precisely to ensure accountability of all controlled substances. Both Fire Medical Specialists are to initial the HFD Daily Controlled Medication Sign-Off Sheet agreeing to the accountability and accuracy of inventory. A new sheet shall be started for each month. It is the responsibility of the Fire Medical Specialists assigned to the station to ensure all HFD Daily Controlled Medication Sign-Off Sheets from the previous year are submitted to the EMS Branch for filing. The deadline for submission is January 31st. 3. The use and administration of controlled substances must be recorded on the Controlled Substances Administration Record as well as the HFD Daily Controlled Medication Sign-Off Sheet by the on-duty Fire Medical Specialist. Once the cap to a controlled substance vial is opened for administration, any unused amount after patient disposition must be discarded and properly documented. ▪ Discarding Unused Controlled Substances: Unused controlled substances along with the syringe and needle utilized must be discarded properly in a designated trash receptacle with a witness present. All discarded controlled substances shall be recorded on the Controlled Substances Administration Record by the on-duty Fire Medical Specialist and then signed by the witness. All fields are to be filled out accurately. 4. Controlled substances are delivered in batches of 5 vials. Once the 5th vial is used/discarded, the Controlled Substance Administration Record is to be signed, dated, and returned back to the EMS Branch for filing. 9000.05 Controlled Substances Standard Operating Procedure Implemented: March 2023 Revised: N/A Next Review: March 2025 5. Expired controlled substances will be collected and inspected for tampering by the EMS Branch. The substances are then cross referenced for accuracy. The Controlled Substances Administration Record can then be signed by the on-duty Fire Medical Specialist and turned in to the EMS Branch for filing. C. Storage of Controlled Substances: 1. To be in compliance with County regulations, controlled substances are to be kept under a double lock system. 2. Each Fire Medical Specialist is assigned a personal code to get in to the medication safe. The personal code to get in to the medication safe is confidential and shall not be shared with anyone. For ambulance safes without a keypad, it is the responsibility of the on-duty Fire Medical Specialist to maintain the integrity of the code to the safe. 3. A controlled substances box shall be placed within the medication safe with a designated key. 4. The key to get in to the controlled substances box within the medication safe falls under the responsibility of the on-duty Fire Medical Specialist. The key should be kept in their possession at all times and shall not be provided to anyone other than the relief Fire Medical Specialist. 5. Notify the EMS Branch immediately if the key to the controlled substances box is lost or misplaced. A new lock box and key will be issued as soon as possible. 6. Ambulances shall be locked when unattended. D. Reporting Discrepancies of Controlled Substances: 1. The Fire Medical Specialist must notify their immediate supervisor and the EMS Branch immediately upon discovery of any controlled substance discrepancies. HFD is required by law to report any discrepancies to the area DEA field office within 24 hours. 2. A police report shall be made when a discrepancy is identified. 3. If a controlled substance is utilized incorrectly, the EMS Branch must be notified immediately. VI. NON-COMPLIANCE: Failure to comply with this policy may lead to disciplinary action up to and including termination. Additionally, controlled substances are governed by State and Federal law and non-compliance with this policy may also lead to criminal penalties.