Narcotic Procedures
The satellite pharmacy located in the Recovery Room dispenses appropriate drugs and solutions for patients in the Operating Room and Recovery Room areas.
The checkout policy for narcotics regarding anesthesiology personnel is as follows:
At 7:30 a.m. the pharmacist obtains the narcotic keys from the mole team resident and inventories the fresh drugs and returned drugs in the narcotics box.
Operating Room and Recovery Room drugs are checked out from the pharmacist by the anesthesiologist. Drugs administered to the patients are logged appropriately in the patient record. Unused drugs are returned to the pharmacist.
After 6:00 p.m., the pharmacist turns the narcotic key over to the first-call anesthesiology resident. From 6 p.m. to 7:30 a.m., the first-call anesthesiology resident is responsible for dispensing narcotics to be used on patients in the operating room. All unused narcotics at night are returned to the night return box.
The following policies must be followed in the handling of narcotics:
Narcotic use slips must be completed accurately by the resident and returned with leftover narcotics after each case. (DO NOT DISCARD LEFTOVERS.) The cc’s of narcotics used on each patient and recorded on the patient’s chart, and the number of cc’s returned must add up to the total checked out.
Syringes and ampules of narcotics must not be left on the anesthesia machine or cart after a case is completed.
Narcotics should be signed out for a specific patient rather than for a whole day’s cases.
Narcotics must not be exchanged between anesthesia personnel unless they are being used on a single patient.
On call personnel should keep the narcotics keys at all times. They should never be left unattended. On weekends, a count will be made whenever on-call personnel change.
The mole team resident who has been on-call will return the keys personally to the OR pharmacist at 8 a.m. each morning. Narcotics should be counted by both the OR pharmacist and resident prior to the resident leaving the operating room area.
Procedure for Writing Prescriptions: Physicians enrolled in
an approved training program, who are not licensed but have a proper
Unlicensed physician ID number, may write prescriptions of all types,
however, a countersignature is necessary when prescribing a controlled
substance(s). All prescriptions must be written on preprinted pads which
contain the prescriber’s name, ID number (required by the DEA), department,
and department phone number and beeper number. Printed prescription pads
shall be considered confidential and shall be secured at all times.
