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Managing your controlled substances

November 24, 2021

Regular, documented counts can help your team track and avoid discrepancies.

One of the most common deficiencies ACP pharmacy practice consultants discover during routine pharmacy assessments is that a process for documenting discrepancies in the pharmacy’s narcotic and controlled substance inventory is lacking. In many pharmacies, discrepancies are not investigated, evaluated, or documented.

ACP offers the following recommendations for tracking a pharmacy’s narcotic inventory to reduce discrepancies:

  • Review the Pharmacy and Drug Act , the Pharmacy and Drug Regulation, and the Standards for the Operation of Licensed Pharmacies (especially Standard 5.11 and 5.12) with regard to your responsibilities in the ensuring narcotic security.
  • Discuss your obligations and the requirements of the pharmacy with your pharmacy’s owner and pharmacy staff to ensure the resources needed to meet these obligations.
  • Ensure that staff are trained to handle narcotics and controlled substances properly. Consider completing a criminal records checks for any unregulated staff who may be involved in handling narcotics and controlled substances and provide direct supervision for all unregulated staff.
  • Conduct narcotic and controlled drug substances counts and document the counts regularly (at least quarterly or more frequently if consistent discrepancies are identified). When there is a discrepancy in the counts, investigate and resolve the discrepancy, and document a summary of your findings. What you document in your findings could help you initiate changes in your pharmacy’s policies and procedures to prevent future discrepancies.
  • Implement and maintain a perpetual inventory for narcotics.
  • After dispensing a narcotic, pharmacy staff should back-count and verify the remaining pharmacy stock against the narcotic’s recorded perpetual inventory.
  • Review on-hand pharmacy narcotic inventory needs and endeavour to keep smaller amounts of narcotics in stock. Be critical! Maintaining smaller quantities of narcotics on-hand will allow pharmacy staff to more rapidly identify changes in trends in narcotics received and/or dispensed. In addition, more periodic narcotic orders resulting from lower on-hand stock levels will result in a greater opportunity for more staff members to be involved in narcotic security and therefore reduce the likelihood of any narcotic diversion by an individual.
  • Keep all clutter in the dispensary to a complete minimum. A disorganized dispensary creates an environment in which diversion is more possible and remain undetected.
  • Use appropriate security cameras.
  • Limit access to narcotics and narcotic ordering and never share narcotic ordering passwords or logins.
  • Implement and review inventory trending software functionalities that alert the pharmacy licensee to changes in narcotic ordering and receiving patterns.

Remember, Health Canada conducts random or targeted narcotic inspections of pharmacies. Maintaining clear and accurate documentation of narcotic counts that includes explanations of any discrepancies is good practice.


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