Securing Controlled Meds

[UnkiEMT]

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.

 

[systemet]

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.

 

[usalsfyre]

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.

 

[usalsfyre]

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

Right

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.

 

[Handsome Robb]

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.

 

[systemet]

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.

 

[Bearamedic]

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.

 

[usalsfyre]

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.

 

[Bearamedic]

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.

 

[Gymratt]

Not an issue here as we carry no narcotics LOL.

 

[ILemt]

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.

 

[TransportJockey]

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.

 

[Carlos Danger]

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.

 

[Nattens]

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.

 

[jwk]

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.

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

 

[Nattens]

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.

 

[drjekyl75]

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.

 

[jwk]

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.

 

[sirguinness]

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.