Department policy v-9: controlled substances

PALM BEACH COUNTY FIRE RESCUE
ISSUED DATE: 6/30/94 REVISED DATE: 8/01/09 IMPLEMENTED DATE: 9/01/09 CONTROLLED SUBSTANCES

SCOPE: This policy applies to all personnel & volunteers of Palm Beach County Fire Rescue.
PURPOSE: The purpose of this policy is to provide for the security, accountability, and inventory
of controlled substances. Controlled substances include, but are not limited to: Morphine, Valium
and Haldol.
AUTHORITY:
Fire Rescue Administrator Medical Director Drug Enforcement Administration (DEA) 21 CFR 1305.04
POLICY: Each Paramedic, Lieutenant or Company Officer assigned to an ALS equipped or
Special Operations unit is responsible for the accurate inventory, administration and documentation
of all controlled substances carried on that unit. The Paramedic, Lieutenant or Company Officer shall
notify the EMS Captain when a controlled substance has been used, found broken, altered, expired or
lost. The EMS Captain is responsible for the timely replacement of controlled substances and the
tracking of the distribution process. The Rescue Division is responsible for reporting missing and/or
lost controlled substances to county agencies, law enforcement and Medical Direction as deemed
appropriate.
PROCEDURE: The following procedure shall be adhered to: inventory, distribute, report broken,
altered, or missing drugs, and document the tracking process with respect to controlled substances.

Storage of Controlled Substances
All controlled substances shall be kept in a clear hard plastic container designed specifically for this
use and carried on each ALS equipped unit. Each container shall be outfitted so that it can be secured
with a numbered, one-way locking plastic hasp. At each change of custody of the controlled
substances it is the responsibility of the Paramedic, Lieutenant or Company Officer to ensure that the
narcotics box is received with an intact numbered hasp and inventoried and distributed as indicated
below.

EMS Captain units will store controlled substances in a metal box with a keyed locking mechanism
due to the larger quantities of substances carried on those units.
All controlled substances will be accounted for at all times regardless of unit status. In the event that
the assigned person(s) responsible for the controlled substances is unable to continue in that capacity,
and there is no relief, then the responsibility for the custody of the controlled substances shall be with
the Company Officer.
Inventory of Controlled Substances
A complete inventory of all controlled substances carried on Palm Beach County Fire Rescue ALS,
Special Operations and EMS Captain units shall be done by the oncoming Paramedic, Lieutenant,
Company Officer and EMS Captain for their individual unit(s).
This shall be accomplished by both the on-coming and off-going crews inspecting the clear plastic
or metal boxes, and physically verifying the quantities, condition and lot numbers of all substances
within the tagged or locked box.
While conducting the inventory, medication containers shall be inspected for any breakages or
alterations. The controlled substance inventory shall be conducted as the first order of business for
the on-coming and off-going crews and at any time during the shift where a change in custody of the
controlled substances occurs.

The controlled substance inventory shall be documented on the "Controlled Substance Inventory
Log" (Form #V-9A). The control, or Lot, number of each vial and/or syringe must be documented
on this form. These line entries are to be made by both the on-coming and off-going crews.
Documenting Usage or Distribution of Controlled Substance
When a controlled substance is used on an incident the narcotics box shall be re-sealed with a new
numbered tag immediately following the removal of the necessary medication, or as soon as
reasonably possible thereafter. On arrival at the hospital any remaining medication must be wasted
and witnessed. The Controlled Substances Distribution Log (Form #V-9B), which is the reverse
side of (Form #V-9A), shall be completed as soon as possible after arrival at the hospital or at the
time of distribution of a controlled substance.
When completing the Controlled Substances Distribution Log (Form #V-9B) all applicable
information must be entered. Usage and/or distribution should be entered on the same numbered
page on which the substance was initially inventoried, which is the reverse side of Form # V-9A.
When completing the ARI incident report the “Controlled Substance Verified By” section in the
narrative must be completed to include the verifying person’s initials and department ID number.

Replacement of Used Controlled Substances
The Paramedic, Lieutenant or Company Officer shall notify the EMS Captain when a controlled
substance has been used, with the corresponding incident number, so that it may be replaced in an
expedient manner. The EMS Captain shall review the corresponding medical report to verify usage
of the controlled substances.
When the EMS Captain delivers the replacement controlled substance the Controlled Substances
Distribution Log ”Given by/Issued by” and “Witness to waste/Received by” columns are to be
completed on the “Controlled Substances Distribution Log” (Form #V-9B) indicating who received
the controlled substance and (Form #V-9C) shall be completed in the EMS Captain’s Log indicating
which EMS Captain/EMS Unit replaced the controlled substance.

Reporting Broken or Altered Controlled Substance Containers
When a controlled substance is found broken, or is accidentally broken, the Paramedic, Lieutenant or
Company Officer must document the occurrence on the Controlled Substances Distribution Log
(#V-9B) and must report it to the EMS Captain who will then notify the Rescue Division. The
Rescue Division will assure that the appropriate departmental notifications are made (Deputy Chief,
Battalion Chief, and Management Services), and that the appropriate action has been completed
according to OP I-43, AReporting Loss or Damage to County Property”. When entering a broken
controlled substance on the "Controlled Substances Distribution Log" (#V-9B) the word "Broken" is
to be entered in the incident number column. The disposal of the broken controlled substance must
be witnessed and the witness must complete the appropriate column.
Reporting Missing/Lost Controlled Substances or Logs
When a controlled substance is found missing/lost or a discrepancy in the count occurs, the EMS
Captain will be immediately notified. He/she will then notify the Rescue Division. After business
hours, the Rescue Division must be paged for notification. The off-going EMS Captain will remain
at the station until the discrepancy is rectified and is released by the on-coming EMS Captain. The
Rescue Division will assure that the appropriate departmental notifications are made (Deputy Chief,
Battalion Chief, and Management Services), and the appropriate action has been completed
according to OP I-43, Reporting Loss or Damage to County Property. Missing logs should be
handled in the same manner as missing narcotics.

Expired Controlled Substances
Personnel are to return ALL expired controlled substances to the EMS Captains assigned to their
respective Battalion.
The EMS Captain can dispose of all expired controlled substances, with the exception of Morphine
Sulfate. This disposal is to be indicated on the Controlled Substances Distribution Log (Form #V-
9B) with all appropriate information entered. The word Aexpired@ is to be written in the Case #

column.
All expired Morphine Sulfate will be hand delivered to the EMS Captain. The EMS Captain will
then hand deliver the expired Morphine Sulfate to the Rescue Division for proper disposal by the
D.E.A.

Pursuant to the manufacturer of the medications, all medications with an expiration date indicating
only the month and year, expire at the end of the stated month. (ex. 5/97 expires May 31, 1997)
Those medications indicating an expiration date with a month, day and year, expire as indicated.
Quantities Carried on Units
The following quantities of controlled substances are carried on Palm Beach County Fire Rescue
Units:
Advanced Life Support Units and Trauma Hawks
5
* Controlled substances carried on Special Operations units shall be stored, inspected and accounted for as previously outlined in this policy. Receiving Controlled Substances from Pharmacy When additional Morphine Sulfate or Valium is required at the Battalion level, the On-Duty EMS Captain will notify the Rescue Division to have the necessary forms completed by the Rescue Division prior to going to the County pharmacy. The Rescue Division will send the completed forms to the County pharmacy for processing. When the Rescue Division receives confirmation that the order is ready for pickup the appropriate EMS Captain will be notified. The EMS Captain will pick up the controlled substances in person and forward any receipts and/or invoices received during this process to the Rescue Division. When additional Haldol is required at the Battalion level, the On-Duty EMS Captain can order directly from the Fire-Rescue Medical Supplies warehouse through either the IBEM system, department e-mail or by contacting the Inventory Specialist directly by phone, depending on needs.

Source: http://ww.palmbeachmpo.org/fire/globals/pdfs/departmentpolicies/V-9.pdf