• 950 Boardwalk Suite 305, San Marcos, CA 92078
    • 760.705.4078
    • tvidals@rxpert.solutions

How Engaged are Your Staff in Maintaining Controlled Substance Security?

Rxpert Solutions > Controlled Substances > How Engaged are Your Staff in Maintaining Controlled Substance Security?

CMS Conditions of Participation states, Abuses and losses of controlled substances must be reported, in accordance with applicable Federal and State laws, to the individual responsible for the pharmaceutical service, and to the chief executive officer, as appropriate.” (482.25(b)(7).

Survey Procedures for this are:

  • Interview the pharmacists, or pharmacy employees to determine their understanding of the controlled drug policies.
  • Conduct a spot check of drug use and other inventory records to ensure that drugs are properly accounted for.
  • Review reports of pharmaceutical services to determine if there are reported problems with controlled drugs and what actions have been taken to correct the situation.
  • Interview the Pharmacy Director, pharmacist and pharmacy employees to determine their understanding of the controlled drug policies. Is there a policy and procedure for handling controlled drug discrepancies?
  • Review reports of pharmaceutical services to determine if there are reported problems with controlled drugs and what actions have been taken to correct the situation.
  • Determine if controlled drug losses were reported to appropriate authorities in accordance with State and Federal laws.

Pharmacy staff need to have an understanding of what policies and procedures are in place for controlled substance security. Not only because they are often the eyes and ears to what is going on within the pharmacy as well as on the nursing units, but they may be interviewed by a surveyor, and they need to be able to speak to the policies. If the staff don’t understand the big picture of why controlled substance security is important and what to do if in the event of an odd occurrence or unaccounted for med, then controlled substance security at the facility is not as tight as you may think it is.

Our References

Terri is absolutely phenomenal. She is an incredibly knowledgeable pharmacy resource. As the medication safety officer, the quality initiatives she implemented not only impacted the patients at our medical center but also reached into the community. Terri is a genuine professional who upholds accountability while creating community among her team members. She is a great listener to identify friction points and has actionable ideas to implement improvements.

Lab
T. Eagle. MBA, MLS(ASCP), CLS Lab Operations Manager

Terri is an expert at prospective risk identification -Failure, Mode and Effects Analysis (FMEA). Terri participated in CHPSO Patient Safety Safe Tables and was part of the Hospital Quality Institute’s Regional Quality and Patient Safety Leader Network.
She is an excellent public speaker and communicates well with public and professional audiences. I look forward to her continued work in medication safety.

Regional Quality Network at HQI
A. Munoz, FACHE, CPHQ, CPPS VP

Terri has done a tremendous job with the controlled substance diversion program. She has had such a positive impact and has really made the hospital a safer place.

Tri-City Medical Center
Nurse Manager

We would not be where we are with the improvements we have made with opioid prescribing if it were not for Terri driving the process.

Tri-City Emergency Medical Group
Chief Physician

In addition to understanding the ins and outs of the [controlled substance use] process completely, she is very proactive in coming to me with provider issues that she detects. She truly balances the administrative duties and the regulatory components demand with a keen sense of what my practitioners do and what their needs are on the ground. Terri is instrumental in working with my department, balancing patient care, cooperation, ability, and integrity to get the job done.

UCSD Medical Center
Chief Anesthesiologist

Terri is knowledgeable and effective in pharmacy leadership. She has the ability to be able to anticipate and prepare for the future. Her ability to utilize resources effectively in this changing environment is a strong asset. She can adapt, evolve, mentor and still never say “no” when asked to assist. She exhibits great abilities to be flexible and is a “self starter”. She has a pleasant yet effective demeanor that commands results.

Candace Fong, Pharm D
System Director of Pharmacy and Medication Safety Common Spirit Health

Terri has always impressed me as being very smart. resourceful, creative, and easy to work with. Terri’s commitment to medication safety permeated our organization, raising the awareness of this important issue throughout all levels of the institution. Terri has always been engaged, cooperative, and generous with her time.

Cary Mells, MD
Chairman of the Department of Emergency Medicine Tri-City Medical Center

Terri has done more for the Pharmacy in her few months as Interim Pharmacy Director than any other Director has done during my 12 years here.

Anita Kennedy, MBA
VP of Ancillary Services Methodist Hospital

Contact Us

Address: 950 Boardwalk Suite 305, San Marcos, CA 92078

  • 760.705.4078
  • tvidals@rxpert.solutions