Accreditation 2023 - Medication Use

Narcotic Safety by Hope Weisenberg and Tina Davidson

Narcotics (or opioids) have been identified as high-alert medications and have a heightened risk of causing significant patient harm when they are used in error. Additionally, their common use in healthcare increases the potential for misuse or diversion in this setting. Therefore, ensuring safe and appropriate use and storage of these medications, particularly high dose formats, are effective strategies to minimize the risk of death or diversion and is a Required Organizational Practice of Accreditation Canada.

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Pembroke Regional Hospital (PRH) prioritizes narcotic safety by providing a system that ensures safe storage, administration, wastage, and monitoring of narcotic and controlled substances. The following strategies have been implemented at PRH:

Narcotic Storage  

• All narcotic and controlled drugs are stored in a designated locked storage cabinet in all patient care areas.
• High dose narcotics (e.g., fentanyl ampoules or vials with total dose greater than 100 mcg per container, hydromorphone ampoules or vials with total dose greater than 2 mg, and morphine ampoules or vials with total dose greater than 15 mg) are not stocked in patient care areas.
• Naloxone is available in the crash cart trays in all patient care areas which stock narcotic substances. 

Standardized documentation and administration of narcotics

• Patient care areas with narcotics use a Daily Narcotic and Controlled Drug Record (DNCDR) to track received, returned, administered, and wasted narcotics. 

Narcotic wastage and disposal

• Narcotic waste is disposed of in designated tamper-resistant pharmaceutical or sharps waste containers, which are regularly taken to off-site facility for incineration.
• Wastage of all narcotic and controlled substances are witnessed and documented by two independent regulated health professionals. 

Narcotic audits and monitoring

• Narcotic counts occur in each patient care area at shift changes when authority is transferred from outgoing shift to the incoming shift and in Pharmacy weekly.
• All staff responsible for narcotic administration will not leave their shift until any discrepancies in counts are reconciled. If error is not reconciled notify the unit manager/delegate during regular hours and Clinical Resource Hospital Charge nurse after hours.  A Risk Incident Management Report (RIMS) is to be completed.
• Any discrepancies in counts are reported to Health Canada within 10 days and an Incident Reporting Information System (IRIS) report is completed.
• Random audits are conducted every 6 months for narcotic administration, ordering and receiving. 

More information on safe use of Narcotic and Controlled Drugs at PRH may be found on the ‘Narcotics and Controlled Drugs’  policy
document and the ‘Pharmacy procedures’ document.