1. (1) The hospital must establish procedures and maintain records to account for all controlled substances and any other drugs designated by the appropriate hospital committee. Records must include:

   1. (a) Name of drug;
   2. (b) Dose ordered, dose dispensed, and dose administered;
   3. (c) Identity of patient;
   4. (d) Date and time of administration;
   5. (e) Person administering the drug;
   6. (f) Verification and documentation of any wasted drug including partial doses.
2. (2) The pharmacy must provide separately locked, securely affixed compartments for storage of controlled drugs and other drugs subject to abuse, except when the facility uses single-unit packaged drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
3. (3) The pharmacy must obtain a delivery receipt for all controlled drugs supplied as floor-stock. This record must include the date, drug name and strength, quantity, hospital unit receiving drug and the signatures of the distributing pharmacist and the receiving nurse.

4. (4) A record must be kept of each administration of a controlled drug from floor-stock. The record must be returned to the pharmacy monthly and the PIC or designee must:

   1. (a) Match returned records with delivery receipts to verify that all records are returned;
   2. (b) Periodically audit administration records for completeness;
   3. (c) Reconcile administration records with inventory and verify that sums carried from one record to the next are correctly recorded;
   4. (d) Periodically verify that doses documented on administration records are reflected in the medical record; and
   5. (e) Initial the returned record and file by date of issue.

Statutory/Other Authority

ORS 689.205

Statutes/Other Implemented

ORS 475.165 & 689.155

History

BP 3-2010, f. 4-29-10, cert. ef. 4-30-10