CONTROLLED SUBSTANCE DISCREPANCY REPORT

Nursing Unit Phone # Date and Time ___________________

Nurse’s Name Patient’s Name ________________________

Instructions for completion: Complete the top portion of this form, select the appropriate item 1-2 by placing an X on the line, write a description of the discrepancy, and fax this form to

2-1204.

IMPORTANT: If unable to resolve discrepancy and the discrepancy is greater than three (3) dosage units, please notify the Controlled Substance Auditor IMMEDIATELY. You may reach the auditor by paging #11283 or 12540.

1. ____ Drug removed in error, package opened; controlled substance contaminated

(tablets, injections, broken plastic seals, etc.).

Name and quantity of Controlled Substance: ________________________________

Cause of contamination: ________________________________________________

2. ____ Discrepancy found, can not resolve.

Give brief description of discrepancy, including date of discrepancy, name and quantity of Controlled Substance, when and by whom the discrepancy was found.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

· Please fax this completed form to the Controlled Substance Auditor at 2-1204.

· Lock Drugs in narcotics cabinet with this form until destroyed by a Controlled Substance Auditor.

When you MAY WASTE:

· Partial dose is ordered; waste the unused portion.

· Patient refuses the medication after it has been prepared; waste the entire dose.

· Practitioner discontinues the order after it has been prepared; waste the entire dose.

· Blood is aspirated into the needle; place syringe with the dose in the dirty needle box.

Every wastage must be performed by a licensed individual and witnessed by a licensed individual.

Every wastage must be recorded in the medstation.

When you MAY NOT WASTE:

· Broken seal or Tamp-R-Tel.

· Tablet crushed or dropped.

· Liquid medication is spilled. Mop up the liquid with 4x4 gauze. Store the syringe (if safe) and gauze in a plastic bag.

Complete this form and fax it to 2-1204. Lock the drug in the narcotics box with the original of this form.

OTC 801943 Rev. 7/01