Co.valencia.nm.us

Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
PURPOSE
This document is intended to provide the information necessary to properly manage and maintain the Controlled Substances
and Dangerous Drugs used by the Valencia County Emergency Services (“Service”). The service has established this
document to meet or exceed the requirements of Federal, State, and Local government agencies and the Pharmacy board, in
order to remain compliant with law.
This document shall serve as the absolute regulation for the receipt, transfer, dispensing, disposal, and storage of Controlled
Substances and Dangerous Drugs.
I. AUTHORITY
A. This document is constructed under the authority of the County Fire Chief, as the appointed manager of the Service B. The Contracted Medical Director, or his designated representative, shall be responsible for reviewing the appropriate dispensation of drugs, and disposal when the drug container was opened and violated, regardless of whether the drug was administered to a patient. C. The Consultant Pharmacist, or his designated representative, shall be responsible for setting the minimum practices and standards for purchase, receipt, transfer, and storage of drugs, including disposal of drugs that are discovered to be damaged or violated without the intent of administration to a patient. The Pharmacist shall also oversee the donation or resale of drugs to accredited training institutions using expired medications for classroom purposes, or student of the department who may be issued such stock. D. The Controlled Substances Coordinator (CSC), or his designated representative, shall be responsible for the security of the master controlled substance stock, and is responsible for the replacement of all schedule 2, 2N, 3, 3N, 4, and 5 drugs, and the storage of all associated documentation. E. The District Supply Officer (DSO), or his designated representative, shall be responsible for maintaining inventory of drugs, consistent with the policies set forth by the Medical Director and Consultant Pharmacist in their respective station and shall also maintain the records of their Service with respect to the content of this document. II. RESPONSIBILITY AND PROCEDURE
A. Controlled Substances are defined as those drugs that require high security and control procedures. Such drugs shall
include, but are not limited to, Morphine Sulfate, Fentanyl Hydrochloride and Diazepam. The Pharmacist may deem any drug that shows potential or history of abuse to be handled according to the following procedures: 1. Acquisition shall be accomplished by the CSC. The replacement stock shall be based solely upon the documentation that initial stock values have been accounted for and no conflicts have been found in the reporting system. No other member of the department, other than the EMS Officer, shall be authorized to procure controlled substances on behalf of the department. Controlled Substances will be obtained from the Pharmacist. 2. Inventory of controlled substances shall be the responsibility of the employees who are permitted to possess them. Members shall sign for accuracy any time an inventory is assessed or transferred. Inventory of controlled substances shall be taken at any time and date in which a change of possession occurs. Inventory values shall be recorded on the Controlled Substances Log, contained in the “Controlled Substance Log Book.” Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
3. Possession of controlled substances is authorized only by employees who are either licensed at the EMT-Paramedic or Intermediate level. All employees who take possession of controlled substances must sign the Controlled Substances Log associated with that unit in which the drug is stored. Controlled substances are to remain on the vehicle assigned. The controlled substance will remain in the KNOX Med Vault to provide the security for controlled substances. 4. Storage of controlled substances may be accomplished in one of three methods only: a. Carried by a licensed EMT-Paramedic or Intermediate on their person, in direct control during patient care or during periods when patients are being accessed. b. Stored within the KNOX Med Vault container on the vehicle to which the drugs are assigned. The container must comply with the standards set forth in Section VI. c. Stored within the stock facility located at the EMS Office at Fire Administration, subject to the same minimum storage standards as set forth in Section VI. 5. Administration of controlled substances shall be accomplished by a licensed EMT-Paramedic or EMT-Intermediate, operating on behalf of the department, on-duty, under protocol or direct medical control, and consistent with law. Administration may also be accomplished by an authorized EMT-Paramedic or Intermediate intern, providing the use is performed under the direct supervision of a licensed EMT-Paramedic or Intermediate, employed by the department. The EMT- Paramedic or Intermediate, must also ensure that no controlled substances are to be transferred to any EMS service or person who is not employed by this department. In the event administration occurs by an unauthorized individual, a report shall be submitted to the CSC. 6. Replacement: The EMS Officer shall be contacted as soon as possible after administration and accomplish the replacement of controlled substances. A copy of the complete EMS Report shall be placed into the “Controlled Substance Log Book.” a. Expired controlled substances shall be the responsibility of the CSC. Once the EMS Officer has been notified, a controlled substance action form will be completed and the container returned to the Master Stock at the Atrium. The expired controlled substance must then be logged back into the Master Controlled Substance Log until properly disposed by the Consultant Pharmacist. b. Damaged controlled substance containers shall be reserved until the EMS Officer can witness the damage and complete a controlled substance action form. c. Drugs opened for use but not administered to a patient shall also require a controlled substance action form from the employee in current custody of the controlled substance and a copy of the EMS report. The container shall be sealed with tape and the contents left intact. If the medication was already drawn into a syringe, the contents shall be wasted into an appropriate drainage/sewer system, and documented and initialed by both EMT Providers on the EMS report. The reports shall be submitted to the CSC and reviewed by the Pharmacist and/or Medical Director. Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
d. Lost or Missing Drugs shall be reported immediately to the District Fire Chief and the CSC. A controlled substance action form shall be completed by all involved parties including the paramedic or intermediate that last opened the KNOX Med Vault for review by the Pharmacist and/or Medical Director. B. Dangerous Drugs are those medications that require a physician’s authorization to administer, but are not classified by
law, the Medical Director, or the Pharmacist as having potential for abuse. Dangerous drugs shall not include oxygen, but may include such drugs as:  Acetylsalicylic Acid (ASA)  Acetaminophen  Albuterol  Adenosine  Atropine Sulfate  Calcium Choride  Dextrose  Diphenhydramine  Dopamine HCl  Epinephrine  Furosemide  Lidocaine  Naloxone  Nitroglycerin  Sodium Bicarbonate  Magnesium Sulfate 1. Acquisition shall be accomplished solely by the EMS Coordinator. Such appropriations shall be logged at the site in which the stock is maintained. No other person is to have access to stock quantities of dangerous drugs. 2. Inventory of storage rooms shall be the responsibility of the EMS Coordinator. Inventory shall be performed at a minimum interval of once per month. Kits shall be inventoried earlier if the kit is used and any quantity of drug is replaced or disposed, those inventories shall be done by the DSO. 3. Possession of dangerous drugs is limited to any member of the service who is licensed to dispense the medication(s) or a member who is working with such a member. Transport by members is permitted, with the understanding that any person who does not possess adequate licensure and medical control may not dispense or administer such drugs. 4. Transfer is permitted between any authorized members of the service. 5. Storage is permitted only upon vehicles owned by the service, unless specialized vehicles are in-use on the scene of a call and within the designated storage station. 6. Administration of dangerous drugs to patients may only be accomplished by those members who possess proper 7. Replacement shall be made at the Supply Station. The DSO will submit a Supply Order form to the EMS Coordinator Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
a. Expired Drugs shall be turned in to the EMS Coordinator, and returned to the Pharmacist for disposal. Alternatively expired drugs can be turned over to students of the EMSA, CNM and UNM-VC that are attending EMS related classes or to the collage for uses of EMS classes, providing that the drug is properly signed out and accounted for. b. Damaged Drugs shall be documented, and if the container is intact, shall be returned to the EMS Coordinator for c. Damaged Containers shall be reported to the EMS Coordinator, and disposed of in an appropriate container. A report shall be submitted, documenting the damage of the container and drug and how the damage occurred. d. Drugs opened for use that are not administered, shall be wasted and a report shall be generated, accounting for the premature violation of the container's integrity and any drug wasted. e. Lost or Missing Drugs shall be reported to the DSO. III. DUTIES OF THE CONSULTANT PHARMACIST:

1. Review all or a sample of instances in which other drugs were used, at least every 90 days; 2. Report in writing any exceptions to the Medical Director and the EMS Coordinator within 24 upon learning of same; 3. Otherwise make a written report to the Medical Director and the EMS Coordinator at least annually on the EMS’s drug handling practices, including corrective action taken on exception; and 4. Such reports shall be available for review by the Board upon request. 5. The consulting pharmacist will develop policies and procedures for EMS regarding Dangerous Drugs per NMAC IV. IN USE LOCATIONS:
Once dangerous drugs have been removed from the Principle Store Facility to be used by the County Rescue, they must be
stored within a jump kit or within a compartment on a mobile unit for emergency use. No Dangerous Drugs can be stored
in any facility other than the Principle Storage Facility.
V. RECORDS AND FORMS
Unless otherwise stated, each station shall maintain paperwork relevant to the stock carried in the service's vehicles and kits
for:
 Controlled Substance Records  Dangerous Drugs Record  Current Stock values for each vehicle and kit.  Reports associated with situations requiring reporting to authority, after the report has been reviewed and actions have been taken, where necessary C. Controlled Substance Action Forms will be kept by the EMS Officer and be utilized to document damage, loss, or Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
D. Controlled Substance Log Forms shall be maintained for any transaction occurring that involved the receipt, use, damage, exchange, or disposal of a controlled substance. The record shall be maintained both centrally at the EMS Office, with the controlled substance master stock and logged at the station where the specific controlled substance is stored or dispensed from. E. EMS run reports shall be submitted for any use of controlled substances, and any use of drugs shall be noted upon it. It is the responsibility of the crew using the drug to make such documentation and for its accuracy. Eventually all EMS run reports shall be stored at the Office of Fire Administration. A copy shall be filed with the CSC if a controlled substance use occurs. 1. A COPY of the signed EMS Report shall be placed into the Narcotics Log Book to be collected by the EMS Officer
2. The EMS Officer will be contacted as soon as possible for initiation of the restocking process. VI. INVENTORY RECORDS REQUIRED
The DSO shall maintain a record of all drugs within their Station. The record shall be maintained in a binder(s), at the site,
and shall be accessible by the EMS Officer.
F. Per Unit/Drug Bag. A listing shall be maintained for each drug box/kit/container, indicating its contents and the
expiration dates for each medication. This log will reflect the on hand stock that is available for immediate use. This
list is the responsibility of the DSO. Each DSO will send in a monthly report showing a full list of in use
medications. SEE FORM 1-A.
G. Per Drug. A listing shall be maintained indicating the quantity of each drug and its location. This log will reflect the total available quantity for each drug, and serve as a guide for ordering. This list is the responsibility of the DSO. VII. DEFINITIONS
Terms contained within the definitions or within this document are intended to be gender neutral. For those occasions where
the word he or his is used, it is implied that she or her can be substituted without changing the intent.
H. County Fire Chief refers to the service head appointed by the County Manager or the Board of County Commissioners to be responsible for the administration of the Service, and in his absence, his designated representative. I. Consultant Pharmacist refers to the licensed Pharmacist under contract to the Service, who functions as the chief executive regarding drug acquisition, storage, accountability, and disposal. J. Contract Medical Director is the licensed Emergency Physician who is responsible for issuing the protocol, guidelines, and standing orders for Emergency Medical Technicians operating under the control and/or authority of the Service. The Medical Director is responsible for establishing acceptable practices for the administration of medications. K. EMS Coordinator refers to an employee of the Service, who is charged with the responsibility of accounting for dangerous drugs and consumable EMS items for the County. Policies & Procedures
Article: 4.3
Effective Date: 08/30/2012
Revised Date:
D A N G E R O U S , D R U G S
A N D C O N T R O L L E D S U B S T A N C E S
L. District Chief refers to the person who is responsible for management of personnel assigned to field positions. This employee is the first point of contact for issues arising from interpretation of this document. The District Chief is to make the decision to pursue matters to higher levels. M. Licensed Provider refers to an authorized Emergency Medical Technician who may have cause to administer a dangerous drug consistent with the Medical Director’s standing orders, protocols, and guidelines at their level of licensure. Physicians and Nurses may be authorized to possess and/or dispense medications, as the Medical Director shall direct. N. Employee refers to any member of the Service who receives compensation in the form of wages earned, and who is subject to disciplinary actions under the Valencia County Personnel Policy. O. Volunteer refers to an unpaid member who bears a field services association with the Service. P. Administration refers to the practice of dispensing a medication orally, sublingually, subcutaneously, rectally, or Q. Possession refers to the carrying of a medication or the keys by which access to the medication can be obtained. R. In Use means when dangerous drugs are removed from the principle store facility and placed in to jump kits or mobile VIII. PHARMACY REGULATIONS
Dangerous drugs are to be secured in Drug Boxes opened upon the need to dispense a drug contained therein. The container
shall be secured on the vehicle to which it is assigned, until used.
All drugs are temperature sensitive and the members of the service shall endeavor to keep the drugs from being exposed to
temperatures colder than 68°F, and no warmer than 77°F. This is to be accomplished by giving consideration to use of
parking features, bay heaters, and air conditioning/heating systems of the vehicle.
All members of the service are compelled to understand their role in regard to pharmaceuticals and are responsible for
reporting concerns and violations.
Each station shall have a copy of the Physicians Drug Reference (PDR), the United States Pharmacopoeia Drug Index
(USPDI) or equivalent. These books may be maintained in the primary vehicle or station, but shall be available to anyone
who asks for it. A copy of the Drug Policy Manual shall be maintained in each station under the same conditions as the drug
reference materials.

Source: http://www.co.valencia.nm.us/departments/fire/Documents/4.3%20EMS%20Dangerous%20Drugs%20%20Controlled%20Substances.pdf