GOG 10-26 Custody and Transfer of Controlled Substances.docx

**PURPOSE:** To establish a standard procedure for maintaining, transferring, and securing narcotics, Diphenhydramine, and anti-emetic medications at ALS Apparatus stations. **SCOPE:** These procedures apply to KCFD personnel with responsibility for supervision, custody, and/or handling of narcot...

**PURPOSE:** To establish a standard procedure for maintaining, transferring, and securing narcotics, Diphenhydramine, and anti-emetic medications at ALS Apparatus stations. **SCOPE:** These procedures apply to KCFD personnel with responsibility for supervision, custody, and/or handling of narcotics, Diphenhydramine and anti-emetic medications assigned to static ALS apparatus. **DEFENITION:** Authorized Personnel -- Shall include Paramedic, Company Officer, EST Personnel, or Field DVC **GUIDELINES:** Narcotics, Diphenhydramine, and anti-emetics (IV and oral) will be stored on ALS apparatus and the narcotics will be contained within sealed drug boxes. Two (2) drug boxes will be stored on each ALS apparatus. Paramedics assigned to these units have primary responsibility for control, custody, and transfer of drug boxes, Diphenhydramine, and anti-emetics. Paramedics shall ensure control of drug boxes, Diphenhydramine and anti-emetics by maintaining them on their person or in the fixed vault on-board the apparatus. Narcotic drug boxes will be sealed with a number coded blue or red security tag. A "Blue Tag" denotes an unopened, fully supplied drug box. A "Red Tag" denotes a drug box that has been utilized and is to be replaced. *Unopened Drug Boxes* Drug boxes will be packaged at the Medical Supply Division (EST) office at Eastwood Trafficway. These drug boxes shall be secured with a number coded "Blue Tag" and assigned to an ambulance. Drug boxes shall remain with an assigned unit, with custody transferring from shift to shift. When shift relief is present, drug box custody transfer will be managed as follows: 1. Off-going and on-coming paramedics are to confirm that both "Blue Tagged" drug boxes are sealed. 2. The on-coming paramedic will record the "Blue Tag" numbers on the Drug Box Log. 3. Off-going and on-coming paramedic will record the number of Diphenhydramine vials, anti-emetic vials and tablets on the drug log. 4. The custody exchange will be complete when both paramedics sign the required signature line of the Drug Box Log. 5. The log is to be maintained in designated folder within the ambulance vault. When shift relief is not present, off-going personnel will manage drug box custody as follows: 1. The off-going paramedic and a company officer overseeing the ALS apparatus will confirm that both "Blue Tagged" drug boxes are sealed; and count the number of Diphenhydramine vials, anti-emetic vials, and tablets. 2. The company officer will record the "Blue Tag" numbers, Diphenhydramine vials, anti-emetic vials and tablets on the Drug Box Log. 3. The off-going paramedic and the company officer shall sign the required signature lines of the Drug Box Log. 4. The log is to be maintained in designated folder within the ambulance vault. 5. Unopened drug boxes, Diphenhydramine vials, anti-emetic vials and tablets for unstaffed ambulances shall be secured in the unit's on-board vault. When prior shift relief was not present, on-coming personnel will assume drug box custody as follows: 1. The on-coming paramedic and a company officer over the ambulance unit will confirm that both "Blue Tagged" drug boxes are sealed; and count the number of Diphenhydramine vials, anti-emetic vials, and tablets. 2. The company officer will record the "Blue Tag" numbers on the Drug Box Log; Diphenhydramine vials, anti-emetic vials and tablets. 3. The on-coming paramedics and the company officer shall sign the required signature lines of the Drug Box Log. 4. The log is to be maintained in designated folder within the ambulance vault. 5. Upon completion of this process, the on-coming paramedic assumes custody and control of the assigned drug boxes. *Opened Narcotic Drug Boxes* After a narcotic drug box (drug box) is opened, the EST office at Eastwood Trafficway will be notified directly by the responsible KCFD personnel.) Following the notification efforts will be made by the EST to provide a replacement drug box prior to the end of shift during which the drug box was opened. When drug box replacement occurs during the shift, the following procedure will be followed: 1. The paramedic will inventory the open drug box in the presence of the assigned EMT and/or the authority providing the replacement. 2. The paramedic will re-seal the open drug box with a "Red Tag" (an unused red tag will be packed in each drug box as part of its inventory for this purpose). 3. The paramedic will record the "Red Tag" number on the Drug Box Log. 4. The paramedic and authorized personnel shall complete the departmental drug inventory sheet and execute the required signatures (see form). 5. Custody transfer of the "Red Tagged" drug box will pass from the paramedic to the authorized personnel providing the replacement. 6. The Authorized personnel will provide a replacement drug box and the paramedic will confirm that the replacement is properly sealed with a "Blue Tag;" 7. The paramedic will record the "Blue Tag" numbers on the Drug Box Log. 8. The custody exchange will be complete when the paramedic and authorized personnel sign the required signature line of the Drug Box Log. 9. The authorized personnel shall promptly return the utilized drug box and accompanying inventory form to the EST office at Eastwood Trafficway. When drug box replacement does not occur during the shift of use and shift relief is available at shift change, the following procedure will be followed: 1. The paramedic having custody of an open drug box at shift change and the relieving paramedic shall jointly inventory the open drug box. 2. The off-going paramedic shall re-seal the open drug box with a "Red Tag;" 3. The off-going paramedic shall record the "Red Tag" number on the departmental drug inventory form. 4. The off-going paramedic shall complete the departmental drug inventory sheet and collect the required signatures (see form); 5. The off-going paramedic shall transfer the "Red Tagged" drug box and accompanying inventory form (placed in the designated envelope) to the ALS apparatus on-board vault, where both will be maintained until collected by an authorized personnel of the EST; 6. Once procedures 1 thru 5 are completed, the on-coming paramedic assumes custody of the "Red Tagged" drug box. When drug box replacement does not occur during the shift of use and **no** shift relief is available at shift change, the following procedure will be followed: 1. The paramedic having custody of an open drug box at shift change and a company officer over the ALS apparatus shall jointly inventory the open drug box. 2. The off-going paramedic shall re-seal the open drug box with a "Red Tag;" 3. The off-going paramedic shall record the "Red Tag" number on the departmental drug inventory form. 4. The off-going paramedic shall complete the departmental drug inventory sheet and collect the required signatures (see form). 5. The off-going paramedic shall transfer the "Red Tagged" drug box and accompanying inventory form (placed in the designated envelope) to the ambulance's on-board vault, where both will be maintained until collected from an Authorized Personnel. 6. The off-going paramedic will contact the on-duty DVC and inform them they are leaving a red tag box.? *Emergency Access of a Red Tagged Narcotic Drug Box* Resealed boxes will only be opened in extreme emergencies. If both boxes are open or resealed the Assistant Division Chief must be notified immediately. *Drug Box Security Issues* If a drug box appears to be tampered with or the security tag numbers do not match the log sheet, the unit having an issue must be taken out of service and the on-duty Assistant Division Chief or DVC working for the shift commander or higher authority must be contacted immediately.