# Securing Controlled Meds



## 18G (May 7, 2014)

What is the common practice for securing controlled medications on your unit. At my agency, the controlled meds are in a locked compartment but the key to open it is kept in plain sight only a few inches away on the action area. This totally defies my own logic but no one else seems to see a problem with it. 

Would this setup be acceptable in your agency or more importantly acceptable with the DEA?

Thanks!


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## MonkeyArrow (May 7, 2014)

It wouldn't be acceptable at my agency. In my agency, only certain people have access to the schedule meds in the station. If we need to restock, we must do it through them (it also helps with accountability to make sure one guy is in charge of the log). As far as it meeting DEA standards, well, it technically is locked. However, the DEA probably has a clause in there that the scheduled drugs must be reasonably safeguarded, or something to that effect.

On the rig, the drugs are in a locked pelican case, in a locked jump bag cabinet accessible from both the interior and exterior of the rig.


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## Tigger (May 7, 2014)

Controlled substances are kept in a small "safe" on the truck, with each truck having its own code. The vials/carpujects themselves are each kept in a sealed shrink wrap packet. In theory the truck is kept in a "locked state" at all times, with the exterior doors locked if out of quarters.

The safes do not lock automatically, and some people are inclined to just leave them open, which is obviously not in compliance. 

My part time operation uses a keyed cabinet, with the key accessible behind a coded lockbox. There are no individual codes.


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## broken stretcher (May 7, 2014)

Each of our ALS providers has a key fob and they must scan and then enter their own personal code that corresponds with their key fob.


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## Medic Tim (May 7, 2014)

We have to have narcs under triple lock in station and on our person or in a safe (single lock with tagged pouch) when in the truck. Luckily we don't have to deal with the dea.


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## TheLocalMedic (May 7, 2014)

Sealed, numbered containers inside a number-sealed lockbox inside of a keyed safe on the ambulance wall.  Four levels of security.  

Basically the only recourse for diverting narcs would be to presumably open all of the locks and seals to access a vial and then not administer any of it while documenting that they received the entire dosage contained in the vial.  Makes diversion a little more difficult, and frankly not worth the bother.


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## Underoath87 (May 7, 2014)

Our narcotics/controlled drugs are kept in clear plastic cases that are secured with a number-stamped zip tie.  

During shift, they are assigned to the medic who places it in his/her drug bag (just a large textile jump bag), which is just secured with a small lock on the zippers and stays in an unlocked compartment in the truck.  The drug bag key stays attached to their ambulance key, which is to remain on their person at all times.


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## cruiseforever (May 7, 2014)

We are required to keep them on our body.


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## DesertMedic66 (May 7, 2014)

Plastic container sealed with a numbered zip tie. When the drugs are on the ambulance they are in a locked cabinet that has a key that is on the unit key chain that are held by the EMT (doesn't make sense to me). And then the unit is locked when we are not in it. 

At station they are all secured in a bolted down safe that requires 2 keys to open. One key the medic has and the other is either a VST or supervisor.


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## rails (May 7, 2014)

TheLocalMedic said:


> Sealed, numbered containers inside a number-sealed lockbox inside of a keyed safe on the ambulance wall.  Four levels of security.
> <snip>



That is probably prudent. A paramedic in my area tells a story of how a former paramedic had opened a bunch of vials, removed the contents, filled the vials with water, and then glued the caps on.

Now the vial caps spin as part of the original seal verification.

I haven't verified the story.


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## DesertMedic66 (May 8, 2014)

rails said:


> That is probably prudent. A paramedic in my area tells a story of how a former paramedic had opened a bunch of vials, removed the contents, filled the vials with water, and then glued the caps on.
> 
> Now the vial caps spin as part of the original seal verification.
> 
> I haven't verified the story.



We just had this happen in our area a couple of months ago. The medic fled when we was busted.


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## lido (May 8, 2014)

TheLocalMedic said:


> Sealed, numbered containers inside a number-sealed lockbox inside of a keyed safe on the ambulance wall.  Four levels of security.
> 
> Basically the only recourse for diverting narcs would be to presumably open all of the locks and seals to access a vial and then not administer any of it while documenting that they received the entire dosage contained in the vial.  Makes diversion a little more difficult, and frankly not worth the bother.


This.  Any system can be broken, but a system that requires documentation anytime you physically touch the narcotics and gives you no reason to do so unless you are giving them cuts down on potential abuse.


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## UnkiEMT (May 8, 2014)

Relatively recently, I became my service's narcotics control officer, and many hours of research later, I can tell you what the DEA considers acceptable.

Basically it comes down to one of two options, either they have to be kept behind two different locks, or they have to be held in the direct control of a single accountable and authorized person.

The concept of two locks is simple enough, but option B is a little harder. The bare minimum is that the box has to be signed out by a person who can administer the drugs and knows exactly what they're signing out, either because they can perform a visual inventory (either by opening the case or by looking through translucent platic) or because a uniquely identifiable tag can be tracked back to to last time the box was opened. It then has to be signed back in by that same person with either no changes or with a use record and if applicable a restock record.


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## mycrofft (May 8, 2014)

rails said:


> That is probably prudent. A paramedic in my area tells a story of how a former paramedic had opened a bunch of vials, removed the contents, filled the vials with water, and then glued the caps on.
> 
> Now the vial caps spin as part of the original seal verification.
> 
> I haven't verified the story.



This was a nursing sort of thing too. And discharging Tubexes then refilling with sterile saline.


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## mycrofft (May 8, 2014)

UnkiEMT said:


> Relatively recently, I became my service's narcotics control officer, and many hours of research later, I can tell you what the DEA considers acceptable.
> 
> Basically it comes down to one of two options, either they have to be kept behind two different locks, or they have to be held in the direct control of a single accountable and authorized person.
> 
> The concept of two locks is simple enough, but option B is a little harder. The bare minimum is that the box has to be signed out by a person who can administer the drugs and knows exactly what they're signing out, either because they can perform a visual inventory (either by opening the case or by looking through translucent platic) or because a uniquely identifiable tag can be tracked back to to last time the box was opened. It then has to be signed back in by that same person with either no changes or with a use record and if applicable a restock record.



How about counting narcs between shifts?
Went to a hospital for DESERT STORM, our admin officer was put to work checking the narcs, and despite their security measures they were fluffing the count each time a new pharmacy officer came in (accepting the "book count" as gospel and thereby forestalling a reckoning). She caught them short of scads of narcs. (HINT: off going person reads the book, oncoming person actually sees/counts the drugs and does not show the reader the real drugs to avoid the reader using that as a prompt).

Last time they tried to fob off _*that*_ duty as a make-work!


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## shfd739 (May 8, 2014)

During shift the vials are in a pouch that is the medic's responsibility to keep up with. 

End of shift if it's a 24hr staffed unit the pouch is passed to the oncoming medic. Non 24hr units and spare pouches are kept in locked ammo cans inside locked cabinets with the rest of the gear (monitor,ALSbag,radios etc). Lock combos are changed semi frequently. 

Each pouch has a paper log for each medic to note/sign the count and track usage/restock on. 

Pretty low tech but it works very well and we rarely have a narc discrepancy or diversion.


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## MagicTyler (May 10, 2014)

rails said:


> Now the vial caps spin as part of the original seal verification.



I used to do this... Untill when I spun a cap on a vial of Valium and it came off. Then I had to write an in incident report, so I don't do that any more. :glare:


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## mycrofft (May 11, 2014)

I used to hate when a narc was signed out but not given and instead of destroying it, they'd try to put it back in the counting device and "correct" the log. 

These drugs are cheap compared to many, so waste properly and press on. Not worth your license and not worth the headache for the next shift to clean up your mess.


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## NomadicMedic (May 11, 2014)

mycrofft said:


> I used to hate when a narc was signed out but not given and instead of destroying it, they'd try to put it back in the counting device and "correct" the log.
> 
> 
> 
> These drugs are cheap compared to many, so waste properly and press on. Not worth your license and not worth the headache for the next shift to clean up your mess.




In the hospital, it's very easy to return a drug to an Omni Cell or Pyxis. Likewise with our field meds. Controlled substances accountability isn't some form of voodoo, it's simply making sure the record keeping is correct.


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## mycrofft (May 11, 2014)

DEmedic said:


> In the hospital, it's very easy to return a drug to an Omni Cell or Pyxis. Likewise with our field meds. Controlled substances accountability isn't some form of voodoo, it's simply making sure the record keeping is correct.



I was working in the stone age. We were just getting computerized drug management when I retired (2010). I understand they are still trying to make it work 100%


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## Handsome Robb (May 11, 2014)

They're inside a key-locked box which is inside of a cabinet which is locked with a 6 digit combination. Each medic is issued a combination when they clear their FTO time.

We used to use Pyxis to check out, in or restock narcotics but I believe we switched to a different system. Not sure though.


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## Angel (May 11, 2014)

wall safe, each medic has a # they can use to open, and a seal/tag on the actual med box

I don't like the idea of carrying narcs on my person.


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## rmabrey (May 11, 2014)

Inside a cheap plano box with a numbered tag. We each have our own that we are responsible for. They stay locked in our individual mailbox when not on shift. Each medic has their own narcs.


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## TransportJockey (May 11, 2014)

Medic holds keys for the locked cabinet. Inside each box is locked as well. Every Monday the ongoing and offgoing medic counts and signs for drugs. Only two medics have access to the drugs on each truck, A-shift and B-shift.


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## usalsfyre (May 12, 2014)

Angel said:


> I don't like the idea of carrying narcs on my person.



Why? If they'll kill you for the narcs they'll kill you for the keys.


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## mycrofft (May 12, 2014)

Because any discrepancy or accident means you just lost the DEA Musical Chairs routine.
And seeing the meds on you could trigger an impulse grab whereas seeing a bunch of keys wouldn't.


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## Hockey (May 12, 2014)

I just don't get what the big thing is about whats in the box.  Okay, Fentanyl and Morphine.  Maybe get some Versed too.  That little high for a few minutes isn't worth losing my job, or my license over.  Ever.  I never will understand why some folks have done it.


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## chaz90 (May 12, 2014)

Hockey said:


> I just don't get what the big thing is about whats in the box.  Okay, Fentanyl and Morphine.  Maybe get some Versed too.  That little high for a few minutes isn't worth losing my job, or my license over.  Ever.  I never will understand why some folks have done it.



That would be the addiction component. As non-addicts, we can't understand the reasoning (or lack thereof) of an addict.


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## Handsome Robb (May 12, 2014)

Angel said:


> I don't like the idea of carrying narcs on my person.



Why not?

Besides zofran, narcotics are the medications I most commonly administer at the bedside prior to moving the patient at all? Makes things overly complicated if you have to run out to the truck to get your narcs every time you want to administer them. 

If anyone ever challenges me for my narcotics with a weapon I'll gladly hand them over. I'd do the same with my keys and digilock code. I was thinking that they should put something into the digilocks so if you input your code backwards it'll still open the safe but will trigger a silent 10-78 alarm in dispatch. I read somewhere that ATMs do that. If you put your PIN in backwards it'll give you money and call the cops. Not sure if that's true or not though.


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## UnkiEMT (May 12, 2014)

Robb said:


> If anyone ever challenges me for my narcotics with a weapon I'll gladly hand them over. I'd do the same with my keys and digilock code. I was thinking that they should put something into the digilocks so if you input your code backwards it'll still open the safe but will trigger a silent 10-78 alarm in dispatch. I read somewhere that ATMs do that. If you put your PIN in backwards it'll give you money and call the cops. Not sure if that's true or not though.



It's not true, moreover, it would be a bad thing if it were, then the guy holding you at weapon point would have incentive to make sure you were using the real code, not the alert code.


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## mycrofft (May 12, 2014)

I wonder how many such stickup occur?
Anyway, if you're the carrier and something's short or funny, here's your next corporate stop:


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## usalsfyre (May 12, 2014)

mycrofft said:


> I wonder how many such stickup occur?
> Anyway, if you're the carrier and something's short or funny, here's your next corporate stop:



And you're entrusted with the responsibility when they're signed out to make sure they come back in the same condition or have a good explanation of why they didn't. It's accountability. I'm accountable to the medical director and the DEA that the narcs are taken care. My field providers, in-turn, are accountable to me. Why is this a reprehensible concept? It's no different than inspecting the $100,000 ambulance you're entrusted with prior to the start of the shift for damage. If you don't, and it comes back nungered, it's on you.

It makes no difference if they were in the lockbox or on you. If they come up missing and there's not a good explanation why, it's your ***.


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## mycrofft (May 13, 2014)

usalsfyre said:


> And you're entrusted with the responsibility when they're signed out to make sure they come back in the same condition or have a good explanation of why they didn't. It's accountability. I'm accountable to the medical director and the DEA that the narcs are taken care. My field providers, in-turn, are accountable to me. Why is this a reprehensible concept? It's no different than inspecting the $100,000 ambulance you're entrusted with prior to the start of the shift for damage. If you don't, and it comes back nungered, it's on you.
> 
> It makes no difference if they were in the lockbox or on you. If they come up missing and there's not a good explanation why, it's your ***.



I'm failing to find the word "reprehensible" in my reply….

And one definition of "under the bus" is "It's your ***". I've seen a couple co-workers blown out then exonerated when they wouldn't lie still after wrongful termination (no investigation).  The winning plaintiffs are required to sign a non-disclosure agreement about settlements, but neither of them were dumb enough to come back and apparently didn't need to.

I had to sit by as a staff nurse during a DEA audit. They don't use the phrase "it's your ***", they systematically ask questions and examine evidence following the _whole_ chain of custody. Any weakness from any aspect is winkled out. Staff training about procedures is tested. Accounting for keys or changing of combinations is examined. 

It's good to be careful about firing people or other changes until after the audit is over, also. 

The gist of my reply was if you receive controlled drugs or anything, inspect it, count it, and do NOT accept it until you are happy with it; if there's something wrong, before you sign, get the boss.


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## Angel (May 13, 2014)

usalsfyre said:


> Why? If they'll kill you for the narcs they'll kill you for the keys.



well i wasnt thinking KILL, lol they can have them before it comes to _that_
i just think its easier to steal (or threaten/assault and take) and/or misplace. also there are no keys, its a wall safe and each medic clicks their own number to open it. any medic on any rig can put in their number and access it.



Robb said:


> Why not?
> 
> Besides zofran, narcotics are the medications I most commonly administer at the bedside prior to moving the patient at all? Makes things overly complicated if you have to run out to the truck to get your narcs every time you want to administer them.
> 
> If anyone ever challenges me for my narcotics with a weapon I'll gladly hand them over. I'd do the same with my keys and digilock code. I was thinking that they should put something into the digilocks so if you input your code backwards it'll still open the safe but will trigger a silent 10-78 alarm in dispatch. I read somewhere that ATMs do that. If you put your PIN in backwards it'll give you money and call the cops. Not sure if that's true or not though.



that would the exception. if i had to for pain mgmt or active seizing ( since thats all we get: morphine, fentanyl soon, and versed) 
but i guess im just overly cautious/paranoid.


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## TransportJockey (May 13, 2014)

Robb said:


> Why not?
> 
> Besides zofran, narcotics are the medications I most commonly administer at the bedside prior to moving the patient at all? Makes things overly complicated if you have to run out to the truck to get your narcs every time you want to administer them.
> 
> If anyone ever challenges me for my narcotics with a weapon I'll gladly hand them over. I'd do the same with my keys and digilock code. I was thinking that they should put something into the digilocks so if you input your code backwards it'll still open the safe but will trigger a silent 10-78 alarm in dispatch. I read somewhere that ATMs do that. If you put your PIN in backwards it'll give you money and call the cops. Not sure if that's true or not though.



I wish I had pockets big enough for my narc boxes.  Lol it does suck to have to send someone to the rig for one of them.


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## usalsfyre (May 13, 2014)

mycrofft said:


> I'm failing to find the word "reprehensible" in my reply….
> 
> And one definition of "under the bus" is "It's your ***". I've seen a couple co-workers blown out then exonerated when they wouldn't lie still after wrongful termination (no investigation).  The winning plaintiffs are required to sign a non-disclosure agreement about settlements, but neither of them were dumb enough to come back and apparently didn't need to.
> 
> ...



I've been the guy in charge of the controlled substances program during a DEA Audit. It's even less fun. 

"Under the bus" to me implies you're being unfairly blamed for system/others failures.

You're last sentence shows we're on exactly the same page. If there's an issue with controlled substances I want to know about it right away, not several days later. Anyone with a controlled substance issue is told to contact their supervisor, and if they don't get told to go OOS till it's resolved, call me directly.


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## Bearamedic (Jun 2, 2014)

cruiseforever said:


> We are required to keep them on our body.



At my place, that is expressly forbidden. The reason being that It makes us a target. 

-----
Locked cabinet near the airway seat, clear number sealed container that allows us to examine at the start and end of each shift, 2 signatures verify intactness at that time. 

Upon usage, sig of wasted amount, management deals with the extras or storage with triple locks.


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## Household6 (Jun 2, 2014)

18G said:


> What is the common practice for securing controlled medications on your unit. At my agency, the controlled meds are in a locked compartment but the key to open it is kept in plain sight only a few inches away on the action area. This totally defies my own logic but no one else seems to see a problem with it.
> 
> Would this setup be acceptable in your agency or more importantly acceptable with the DEA?
> 
> Thanks!



That's our setup. Then counted and signed for every shift change. Single use vials where the dose is recorded and the rest must be squirted into a wastebasket in front of your partner.


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## Clare (Jun 2, 2014)

Controlled drugs (morphine, fentanyl, ketamine) are stored in the drug safe which is locked, then stored inside the stores room which is also locked.

They are carried in a belt pouch on the person of somebody who has authority to possess them.  

Personally I do not understand the logic in having them (double) locked in the ambulance; what a waste of time having to go back to get them or take them out on every job; you never know when you are going to need them/


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## jwk (Jun 2, 2014)

It's a comparable problem anywhere controlled substances are kept.

In general, according to DEA, they are supposed to be kept behind two locks, even in the hospital.  So if the pharmacy is locked, and they're kept in a locked cabinet, that satisfies the requirement.  If a pharmacist is present, then the first lock requirement is obviously unnecessary.  But if the pharmacist leaves the pharmacy, and this happens both in the hospital as well as retail stores, the pharmacy is supposed to be closed off and locked.  If your rig is locked, and the narcs are in a locked cabinet, the requirement should be satisfied as well.  

Carrying them around might be a different issue.  If you're taking them out with the intent to use them on a given patient, you should be fine.  If you take them out to carry them around just in case, that might be more problematic.  I can't check out controlled drugs in the hospital "just in case".  They have to be for a specific patient.  It didn't used to be that way, but it's much more controlled nowadays than it used to be.  I think you're much more at risk for accidental loss or broken amps/vials/pre-loads by carrying them around, and of course a broken vial is supposed to be documented as a narcotic discrepancy.

Don't know how it is with EMS, but any time we start accumulating discrepancies in the hospital, regardless of the reason, it will raise eyebrows.  I will show the broken vials to the pharmacist and have them document, or, I will tape broken pieces of the vial, with the label, to the narcotic discrepancy form.  Too many discrepancies in too short a period of time, and we get to go pee in a bottle with a witness - refuse and you're fired - it's that simple.


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## UnkiEMT (Jun 3, 2014)

jwk said:


> Carrying them around might be a different issue.  If you're taking them out with the intent to use them on a given patient, you should be fine.  If you take them out to carry them around just in case, that might be more problematic.  I can't check out controlled drugs in the hospital "just in case".  They have to be for a specific patient.  It didn't used to be that way, but it's much more controlled nowadays than it used to be.  I think you're much more at risk for accidental loss or broken amps/vials/pre-loads by carrying them around, and of course a broken vial is supposed to be documented as a narcotic discrepancy.



Inherent for us is that our narcs aren't pulled for specific patient use, since we have no idea what patients we'll have or what needs they'll have when we roll away from base. The schedule V/IV/IIIs are all prescribed by the medical director to the service, essentially "for office/clinic use", the schedule IIs we pick up with a 222 from our own DEA MLP license.

Further, and if anyone cares I'll find the cite, we're allowed to bypass the two locks rule by carrying them on the person and in the direct control of an authorized administrator...I can't remember off the top of my head whether they have to be sealed or not, I didn't pay much attention since I couldn't imagine not sealing them.



> Don't know how it is with EMS, but any time we start accumulating discrepancies in the hospital, regardless of the reason, it will raise eyebrows.  I will show the broken vials to the pharmacist and have them document, or, I will tape broken pieces of the vial, with the label, to the narcotic discrepancy form.  Too many discrepancies in too short a period of time, and we get to go pee in a bottle with a witness - refuse and you're fired - it's that simple.



Discrepancies are a problem for us as well, the biggest problem with them though is that there's some rather vague language in the DEAs rules. Specifically, the process for a loss requires an internal investigation (always) and a notification of appropriate responsible LEOs (If applicable), and then a notification of the DEA if it qualifies as a "significant loss", but they don't define what a significant loss is.


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## systemet (Jun 5, 2014)

I should probably state that I'm not working in the US, so local laws are obviously different.

One of the places I work, the medic carries 400 ug of fentanyl, 40mg morphine, 20 mg midazolam and 4 mg lorazepam, and the EMT carries 400 mg of ketamine in belt pouches.  This is a fairly high-crime area, and, to my knowledge, no one has been attacked for their narcotics.  As with many places, there have been sporadic cases of abuse by the staff.  When the trucks OOS, the narcs are double-locked.  Replaced through pyxis with fingerprint, x 2 staff members.

The other, perhaps even higher crime area, I work, we have everything in a narc safe mounted in the truck, that needs either the medic or EMT to enter a six-digit code.  There, we carry about twice as much of everything, and also control the roc, sux, and even toradol, gravol, zofran and maxeran.  There were too many issues of things being stolen.

I personally prefer having them on my person.  I'm not sure about your guys dispatch, but mine is not very reality-based or information-rich.  It's nice when you walk into a multi-storey building, prison, etc., and have the drugs right there.  It's a little difficult to have a kid with 20% BSA burns and have to send someone back to the truck for ketamine and fentanyl, and so forth.  Does this happen a lot?  Not really, but it's nice if it doesn't have to happen at all.


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## usalsfyre (Jun 9, 2014)

jwk said:


> It's a comparable problem anywhere controlled substances are kept.
> 
> In general, according to DEA, they are supposed to be kept behind two locks, even in the hospital.  So if the pharmacy is locked, and they're kept in a locked cabinet, that satisfies the requirement.  If a pharmacist is present, then the first lock requirement is obviously unnecessary.  But if the pharmacist leaves the pharmacy, and this happens both in the hospital as well as retail stores, the pharmacy is supposed to be closed off and locked.  If your rig is locked, and the narcs are in a locked cabinet, the requirement should be satisfied as well.


 You're reading the wrong part of the regs. EMS falls under provider and not facility rules.


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## usalsfyre (Jun 9, 2014)

Bearamedic said:


> At my place, that is expressly forbidden. The reason being that It makes us a target.


Right  



Bearamedic said:


> Locked cabinet near the airway seat, clear number sealed container that allows us to examine at the start and end of each shift, 2 signatures verify intactness at that time.
> 
> Upon usage, sig of wasted amount, management deals with the extras or storage with triple locks.



If your management is naive enough to think those seals can't be defeated they're in for a rude awakening one day.


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## Handsome Robb (Jun 9, 2014)

usalsfyre said:


> If your management is naive enough to think those seals can't be defeated they're in for a rude awakening one day.



It's not a requirement but it's strangly encouraged and will always get brought up, that we document the cap of a vial was free spinning prior to us opening it. We've had a few problems with diversions in the past. Even with that we still carry narcs on us. I've never seen an SOP about it but every medic that I know carries at least some narcs in their pocket. We carry 600 ug of fent, 40 mg of versed and 40 mg of morphine. I carry half and lock half. We have so many casinos, hotels and large apartment buildings that it would be silly to not carry any on your person. Especially since I'm the one with the keys and the code and I will not share that code with anyone so i'd have to be the one to go get them which isn't always an option. Ok...I'd give the code to someone who was asking for it with a weapon but other than that, no. Not even my partner.


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## systemet (Jun 9, 2014)

usalsfyre said:


> If your management is naive enough to think those seals can't be defeated they're in for a rude awakening one day.



Agreed.  

Unfortunately, I think it's impossible to design a system where a provider has access to controlled substances to perform patient care, but all risk of diversion / abuse has been removed.

I think the employer ultimately has a responsibility to make sure they are compliant with local statutes, and to provide reasonable safeguards. If the employer can show they have a relatively robust system of protection, then they probably have less liability.


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## Bearamedic (Jun 10, 2014)

usalsfyre said:


> If your management is naive enough to think those seals can't be defeated they're in for a rude awakening one day.




There maybe some ambiguity in how i worded it, but the containers themselves are clear, allowing us to inspect the contents for intact paper seals, and we can pop the numbered tag seals anytime we want with management witnesses and usually phone video recordings.


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## usalsfyre (Jun 10, 2014)

Bearamedic said:


> There maybe some ambiguity in how i worded it, but the containers themselves are clear, allowing us to inspect the contents for intact paper seals, and we can pop the numbered tag seals anytime we want with management witnesses and usually phone video recordings.



Does it take that to actually GIVE the meds? Sounds like your company needs to focus on hiring more trustworthy people as "failsafe" systems rarely are. 

The point of all this rambling is that the real key to controlled substance security is good people backed up with incentive to do the right thing (i.e. not go to jail). It's not gee whiz devices.


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## Bearamedic (Jun 11, 2014)

usalsfyre said:


> Does it take that to actually GIVE the meds? Sounds like your company needs to focus on hiring more trustworthy people as "failsafe" systems rarely are.
> 
> The point of all this rambling is that the real key to controlled substance security is good people backed up with incentive to do the right thing (i.e. not go to jail). It's not gee whiz devices.




Oh. nope we dont need two signatures to give the meds. once the vials are opened, all we have is a runsheet to suggest that we didnt steal the drugs and give the patient a dilution while in the back. 

I know of no drug issues at my company, but we've always played it safe i guess. Several managers were also leo. That might explain the paranoia.


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## Gymratt (Jun 19, 2014)

Not an issue here as we carry no narcotics LOL.


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## ILemt (Aug 6, 2014)

At my service, the regular meds are kept in a tackle box sealed with a numbered zip tie. 
This sits otherwise unsecured in the back next to the monitor.
Narcs ( morphine, fentanyl, versed) and carbojects are kept in a clear box with a pair of numbered zipties. At shift change, the medic of the offgoing shift and the medic of the oncoming shift verify that the seals of both boxes are undamaged and document the seal numbers in a log book ( may change to an app in the laptop soon). Both people sign the log, the narcs and log are placed into a secure compartment near the jump seat and the on-coming individual secures the cabinet with his/her personal padlock, the key of which remains on their person at all times. While conducting rig check, the jr member of the new shift initials on HIS form that the change over occured.

Inside both drug boxes is a slip of paper with the name and signature of whatever pharmacist filled and ziptied the box at the hospital, along with the tie numbers.

If a drug box is opened for any reason, or the lock damaged, the crew must take the box and drug log to the pharmacy. The pharmacy verifies the box by checking the internal form with their own log, and if drugs were used, a copy of the run sheet, signed by the crew and accepting facility staffer must be submitted to the pharmacist. Empty vials must be turned in as well as any unused portion. Narcs are wasted in the pharmacy with yet a third form being signed by the pharmacist and medic.

Pain in the *** all around, but the area has had some med theft issues both in ems and in the pharmacies.


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## TransportJockey (Aug 6, 2014)

So I'll update this since I just moved trucks recently. MY current truck has no keys for the narcs carried by anyone. We have a keypad safe with a key inside for the locked fridge (which has our Anectine, Lorazepam, Rocuronium, and Racemic Epi in it). In the keypad safe there's Morphine, Demerol, Dilaudid, Fentanyl, Versed, Valium, Vecuronium, Propofol and Ketamine. The truck is set up this way since there are two medics on it on my shift (both CCP trained) so they didn't want us to worry who had keys. 
We are working on a deal to carry a small set of pain management options in a case on our person (most likely Fentanyl and Ketamine), but we need to find an appropriate case.


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## Carlos Danger (Aug 7, 2014)

We had two large bags, our "scene bag" and our "interfacility bag".

The scene bag was a Thomas backpack with our airway stuff, IV/IO stuff, invasive procedure stuff, and some random important bandaging items. Inside the airway bag (which was carried inside the scene bag) was a pouch with RSI meds and some first-line code drugs; when you opened up the bag to get out your laryngoscope and ETT, the sux and etomidate were right there. The idea was that this bag and your monitor was all you needed to fully manage a patient from initial contact through the short time until you got them back to the helicopter.

The interfacility bag was a sturdy duffle bag which housed our IV pumps, vent circuit, more ACLS meds, and all the other meds that you rarely use outside of an interfacility transport. We also had a makeshift fluid warmer that kept our IV bags from freezing and our mannitol from crystalizing. 

Finally, controlled substances were kept in a pouch which was carried in the leg pocket of our flight suits. Didn't carry much by the time I left; lorazapam (which we only had because it was mandated by the state), midazolam, and fentanyl I think is what we had whittled it down to over the few years I was there. The contents of the pouches (we had several spares that were double locked in a case on the wall in dispatch) were inventoried and double signed by the off going and oncoming flight paramedic at every shift change.

It was a nice, fairly minimalist set up.


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## Nattens (Aug 8, 2014)

Thought I'd give a contribution on how we secure our medications over here in Australia (Specifically Victoria). A standard ALS paramedic branch carries Morphine 10mg in 1ml, Fentanyl 100mcg in 2ml and 600mcg in 2ml, Methoxyflurane 3ml and Midazolam 5mg in 1ml.

-The drug bag carried in the truck isn't locked closed or cable tied however it is a requirement that the ambulance is locked at all times including when in the branch garage. Drugs are signed to and from the main branch safe at the start and end of the shift.

-The drug safe in the branch requires swipe card access to open and all access is logged. Has a larger amount in storage than that which is in the drug bag.

All medication logs are audited by the team manager fortnightly and the group manager quarterly to ensure compliance.


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## jwk (Aug 8, 2014)

Nattens said:


> Thought I'd give a contribution on how we secure our medications over here in Australia (Specifically Victoria). A standard ALS paramedic branch carries Morphine 10mg in 1ml, Fentanyl 100mcg in 2ml and 600mcg in 2ml, Methoxyflurane 3ml and Midazolam 5mg in 1ml.
> 
> -The drug bag carried in the truck isn't locked closed or cable tied however it is a requirement that the ambulance is locked at all times including when in the branch garage. Drugs are signed to and from the main branch safe at the start and end of the shift.
> 
> ...



600mcg Fentanyl in a 2cc amp?  That's a little strange by anyone's standards.


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## Nattens (Aug 8, 2014)

jwk said:


> 600mcg Fentanyl in a 2cc amp?  That's a little strange by anyone's standards.



Normally yes but that ampoule is for intranasal administration only.

Doses are 200mcg loading and 50mcg repeats at 5/60 for patients >60kgs and <60yo and 100mcg loading and 50mcg repeats at 5/60 for patients <60kgs and >60yo. For paeds the dose is 2mcg/kg loading and 1mcg/kg repeats at 5/60. For children <25kgs this is drawn up from the 100/2 presentation.

They used to have a 900mcg in 3ml ampoule for the IN doses but reduced it due to the amount of wastage that was occuring.


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## drjekyl75 (Aug 9, 2014)

Our system isn't the most secured. We carry a large orange "tackle box" that is sealed with a plastic lock. All the narcs are in pill bottles with a sticker over them. My company has a locked cabinet that the drug box is in inside the truck. The cabinet is locked with a key, but all employees in the company have a key. Its policy to lock the truck when not in it whenever possible.


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## jwk (Aug 9, 2014)

Nattens said:


> Normally yes but that ampoule is for intranasal administration only.
> 
> Doses are 200mcg loading and 50mcg repeats at 5/60 for patients >60kgs and <60yo and 100mcg loading and 50mcg repeats at 5/60 for patients <60kgs and >60yo. For paeds the dose is 2mcg/kg loading and 1mcg/kg repeats at 5/60. For children <25kgs this is drawn up from the 100/2 presentation.
> 
> They used to have a 900mcg in 3ml ampoule for the IN doses but reduced it due to the amount of wastage that was occuring.


You Aussies have all the fun stuff - especially the MOF inhalers.


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## sirguinness (Aug 29, 2014)

The narcotics are stored in a double-locked cabinet on the truck or the paramedic can carry them on his/her person.  For an administration we need to fill out a paper and electronic administration record with waste witness signatures.  However if we use the entire balance then we don't need one.  At station they are secured in a locked room with a Pyxis and need a witness when returning them.  During crew change we are (supposed) to pull them out and verify with the on/off going medic.  People are extremely lax around here with them.


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