Compliance with Recommended Practices for Management of Controlled Substances in a Health Care Facility and Corrective Actions

Abstract

Pharmacists are required to maintain a secure inventory of medications and to ensure proper, safe, and diversion-free dispensing practices. The primary objectives of this study were to determine compliance with recommended practices for the management of controlled substances in a mother-child teaching hospital and to identify actions to improve compliance. The secondary objective was to identify steps in the drug pathway for controlled substances and associated failure modes in the study hospital. This descriptive cross-sectional study used a framework developed by the California Hospital Association (CHA) to assess compliance with recommended practices for the management of controlled substances in hospitals. For each criterion, a research assistant observed practices within the pharmacy, on patient care units, at outpatient care clinics, and in operating and delivery rooms. The level of compliance was recorded as compliant, partially compliant, or noncompliant. An Ishikawa diagram was developed to illustrate steps in the drug pathway and associated failure modes related to the use of controlled substances in the study hospital. The pathway for controlled substances at the study hospital was compliant for 56 (49.6%) of the 113 CHA criteria, partially compliant for 27 (23.9%) of the criteria, and noncompliant for 24 (21.2%) of the criteria; the remaining 6 (5.3%) criteria were not applicable. This practice evaluation highlighted 22 corrective actions, 12 (55%) that could be implemented in the short term, 8 (36%) suitable for implementation in the medium term, and 2 (9%) suitable for both the short and medium term. A total of 57 potential failure modes related to the use of controlled substances were identified. The pathway for controlled substances at the study hospital was compliant with almost half of the CHA criteria, and 22 corrective actions were identified. Pharmacists, physicians, and nurses should be mobilized to optimize the use of controlled substances throughout the drug-use process.