510.31 Controlled Substance Accountability

LAS VEGAS FIRE & RESCUE

STANDARD OPERATING PROCEDURES

1. INTRODUCTION

1. Purpose:To provide for adequate storage, handling, and documentation of controlled substance use by Las Vegas Fire & Rescue to meet Federal, State, and ClarkCounty regulations and to provide adequate safeguards to the patients and employees of the City of Las Vegas.

1. Scope: All Fire Department suppression personnel are responsible for being aware of and following the procedures when dealing with controlled substance utilization and re-supply.

1. Author: The Deputy Chief of EMS, through the S.O.P. Coordinator, shall be responsible for the content, revision and annual review of this instruction.

1. RESPONSIBILITY

1. It is the responsibility of theLas Vegas Fire & RescueMedical Director,EMS Field Coordinators, BattalionChiefs, Company Officers, and Paramedics to follow this procedure and ensure the security and accountability of controlled substances.

1.The Deputy Chief of EMS

a)Audit the records of EMS Field Coordinators to ensure accountability.

b)Notify the Medical Director when violations of this procedure occur.

2.Battalion Chiefs

a)Work with the EMS Field Coordinators to ensure that any incidents involving controlled substances are dealt with in a prompt and efficient manner.

3.Company Officers

a)Upon discovery, notify the Battalion Chief and EMS Field Coordinators anytime a member of his/her company leaves at shift change without inspecting and signing the controlled substance logbook.

b)Under the following circumstances, provide written notification to the Battalion Chief and EMS Field Coordinators via electronic mail:

(i)Medication error occurring during incident.

(ii)Southern Nevada Health District Protocol deviation regarding controlled substances.

(iii)Controlled substance containers with a broken tamper-proof seal (lock).

(iv)Any other situations related to controlled substances where the Paramedicfeels notification should occur.

4.EMS Field Coordinators

a)Coordinate delivery, accountability, and use of controlled substances.

b)Track the tamper-proof seal (lock) numbers on controlled substancescontainers.

c)Verify documentation of medication administration in the Controlled Substance Administration record of the Las Vegas Fire & Rescue Controlled Substance Daily Log book.

d)When notified, replace controlled substance containers.

e)Inspect all opened controlled substance containers and ensure proper documentation for disposing of controlled substance.

f)Inspect the Las Vegas Fire & Rescue controlled substance Daily log books for any unit with missing signatures and report to the Medical Director, appropriate Battalion Chief and Captain.

g)Forward completed controlled substance logbooks to the Medical Director for three-year records storage.

5.Medical Director

a)Maintain full responsibility and authority for the Controlled Substance accountability and re-supply program.

b)Order controlled substances and coordinate delivery, accountability, and use.

c)Assemble the approved controlled substance containers with one record of the earliest expiration date of all controlled substances enclosed in the approved container. This record will be written on the red tamper-proof seal (lock) in permanent marker before issued to any Advanced Life Support unit.

d)Track the tamper-proof seal (lock)numbers on controlled substances containers.

e)In all circumstances, the transfer of controlled substances must be documented in the Las Vegas Fire & Rescue Controlled Substance Daily Log book.

1. DEFINITIONS

Controlled Substance:

The term ''controlled substance'' means a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of DEA Controlled Substance Act. The term does not include distilled spirits, wine, malt beverages, or tobacco, as those terms are defined or used in subtitle E of the Internal Revenue Code of 1986.

1. POLICY

It is the policy of Las Vegas Fire & Rescue to account for all aspects of storage, inspection, handling, dispensing, administration, and recordkeeping of controlled substances. Controlled substances that will be stocked for use by Las Vegas Fire & Rescue will be determined by Southern Nevada Health District Advanced Life Support Medication Inventory, theLas Vegas Fire & RescueMedical Director, and EMS Operations staff. Controlled substance purchase will be done with an approved pharmacy under a written agreement.

1. PROCEDURES

1. Storage

1. Controlled substances will be dispensed to Advanced Life Support Units in containers approved by the Medical Director

1. Controlled substances containers will have tamper-proof seal (lock) with a tracking number.

1. The approved containers will have one record of the earliest expiration dateof all controlled substances. This record will be written on the redtamper-proof seal (lock) in permanent marker before issued to any Advanced Life Support Unit

1. All controlled substances shall be stored in a securely locked cabinet on the unit and in direct control of the Paramedic assigned to that unit that all times. Only the Paramedic(s) assigned to that unit will have the keys to access the cabinet containing the controlled substances.

1. Storage conditions, should not expose the drugs to extreme light, heat (over 80 degrees), or cold (below 32 degrees) for greater than one hour at a time.

1. Records

1. Anytime there is a paramedic personnel change on an Advanced Life SupportUnit, the controlled substance container will be inspected for correct inventory, intact tamper-proof seal (lock), expirationdate on tamper-proof seal (lock), and tracking number of tamper-proof seal (lock). This will be completed with the presence of the off-going and oncoming Paramedic. TheParamedics will document in the Las Vegas Fire & Rescue Controlled Substance Daily Logbook that both have inspected the controlled substance container and the tamper-proof seal (lock), and then log the tracking number of the tamper-proof seal (lock).

1. Administration

1. Controlled substance container’s tamper-proof seal (lock)will only be broken in the event ofexpected controlled substanceadministration. A unit dose of a controlled substance will onlybe used on a single patient and any unused portion will be disposedof.

1. Whenthe controlled substance administration is complete for the incident, the paramedic will use the enclosed yellow tamper-proof seal (lock) and seal the controlled substance container. The control substance container shallonly includecontrolled substances that are not opened. The yellow tamper-proof seal (lock) tracking number will be recorded in the Las Vegas Fire & RescueControlledSubstance Daily Log book. The yellow tamper-proof seal (lock) may be broken if controlled substance administration is required before being restocked by the EMS field coordinator.

a)The Paramedic that administered the controlled substance will fill out aLas Vegas Fire & Rescue prescription form approved by the Medical Director

b)Each time a controlled substance is administered, it will be recorded in the Las Vegas Fire Rescue Controlled Substance Daily Logbook with the administering paramedic and the incident number.

c)Notification of the EMS Field Coordinator will be done as soon as possible after administration of any controlled substance.

NOTE: Las Vegas Fire Rescuedoes NOT authorize the transferring or receiving of controlled substances to or from another agency.

1. Disposal/Destruction

a)Each time there is an unused portion of a unit dose of a controlled substance, the unused portion shall be disposed.

b)The disposalof a controlled substance shall be done with a Physician, Registered Nurse, or Paramedic. The paramedic and person witnessing the disposal will sign and print their name on the Las Vegas Fire & Rescue prescription form.

1. Replacement/Outdated/Damaged Drugs

a)The EMS Field Coordinator will replace controlled substance containers on Advanced Life Support Units. The EMS Field Coordinator will replace containers if:

• Opened forpatient administration
• Damaged or tampered containers
• When the controlled substance containeris considered expired.

b)The EMS Field Coordinatorwill replace expiring controlled substance containers two weeks before the controlled substance isdue to expire.

c)The new controlled substance container will be added to the Las Vegas Fire & Rescue Controlled Substance Daily Logbook with new tamper-proof seal (lock)tracking number noted.

1. Unexpected Situations

1. When an Advanced Life Support Unit is taken out of service, the controlled substances will be secured on the unit, secured with the Paramedic,or transferred to another unit. This will be at the discretion of the Paramedic responsible for the controlled substances.

1. In an emergency situation (e.g., family emergency, injury/illness, or unexpected event) where the Paramedic has to leave his/her assignment before another Paramedic arriving, the controlled substance container will be secured on the unitor signed over to another paramedic in that station.

1. In the instance that the controlled substance container is secured on the unit, the narcotic box key will be signed over to another paramedic in that station.

1. In all circumstances, the transfer of controlled substances must be documented in the Las Vegas Fire Rescue Controlled Substance Daily Logbook.