ADMISTRATION OF

CONTROLLED NARCOTIC AND

CONTROLLED NON- NARCOTIC
MEDICATIONS
PURPOSE
To ensure safe handling, storage,
administration and documentation of
controlled narcotic medications and
controlled non- narcotic medications

SCOPE
All registered nursing staff

POLICY
All registered nurses are responsible and
accountable to ensure safe handling, storage,
administration and documentation of controlled
narcotic medications and controlled non narcotic
medications.

HEAD NURSES/DESIGNEE
RESPONSIBILITIES
Head

Nurses should designate one

registered nurse fro each shift to be
responsible for holding the controlled
medication cabinet keys.
Controlled medications must be counted,
recorded and signed for in the controlled
medication check register by the two (2)
designated nurses: outgoing and the
incoming nurse on every shift.

 In

the event when the designated nurse has

to leave the ward, the controlled
medication cupboard keys should be handed
over to another registered nurse. Upon
returning, the designated nurse should
safely receive the keys and report on the
use of any
The Head Nurse/ Acting Head Nurse should
undertake a weekly check of controlled
medications.

THE DESIGNATED NURSE SHOULD

ENSURE THAT:
All

controlled medications are

correctly ordered and safely stored.
Nearing expiry date (three months) or
those that are no longer required
should be returned to the pharmacy.

 Adequate

ward stock levels are

maintained.
All relevant documentation is
accurately completed.

ORDERING AND COLLECTING

CONTROLLED MEDICATIONS FOR
WARD STOCK
Each

medication must be ordered on a

separate page using the controlled
order book.
The nurse ordering the controlled
medications must print the medication
name, strength, quantity and legibly
print and sign the name in black ink.

 The

nurse collecting the medications

must always check the strength ,
quantity, expiry, date and any
discrepancies(e.g.
broken/empty
ampoule/missing tablets) relating to
each individual order in the presence
of the pharmacist prior to signing the
controlled medication card and the
order book.

ORDERING AND COLLECTION OF

CONTROLLED MEDICATIONS FOR
NON-WARD STOCK
The

controlled medication ordering book

should always be used.
A physicians order together with
relevant section of form #0220 should be
appropriately completed (for controlled
narcotic) and forwarded to the pharmacy
for each dose.

 The

nurse collecting the medications must

always check the strength, quantity, expiry
date and any discrepancies (broken/empty
ampoule/missing tablets) relating to each
individual order in the presence of
Pharmacist prior to signing the green
card(Form No. 0216)

STORAGE OF CONTROLLED
MEDICATIONS
The

controlled narcotic medications must

kept locked in the inner section of the
narcotic cabinet and the controlled nonnarcotic in the outer section of the cabinet.
The controlled medications cabinet must be
kept locked at all times, and the keys to both
the cabinets must always be carried by the
designated nurse.

 Before

storing the medications, the nurse

bringing the ordered medications from the
Pharmacy together with a second registered
nurse, should carefully re- check the details
and then appropriately document them in
the order and check book.
The controlled medication ordering books
and card should be filed in a binder and
safety locked inside the cabinet.

ADMINISTRATION OF
CONTROLLED MEDICATIONS
All

the medications must be administered

according to the prescribed orders from the
physician, resident grade and above, and
should clearly indicate the medication name,
dosage, route and the time for administration.
The registered nurses should administer all
controlled
medications
by
oral
and
intramuscular routes.

 The

mixing and diluting of all the controlled medications

can only be performed by either the pharmacist and /or by
the registered nurses in critical care areas.
All the controlled medications must be checked,
administered, witnessed and signed for by two registered
nurses using appropriate forms.
All ward narcotic medication ampoules must be saved for
return to the Pharmacy Department.
In Operating Department, opened controlled medication
ampoules/vials can be used more than once according to the
following manufacturers guidelines and departmental area.

Normally all the medication from open

ampoules should be used immediately.
Ketamine

vial should be used 24 hours and

discarded. Remaining vials should be kept and
return.
An Ampoule of prescribed controlled medication
can be used for more than one patient according
to the following pharmacy guidelines:
The prescribed medication ampoule must be used
immediately for the required patients.

Where

more than One patient is to receive a

prescribed controlled medication from same
ampoule:
a. The medication should be administered
immediately as prescribed and any remainder
should be discarded and documented in the
presence of the witnessing nurse.
b. Form no. 220 must be completed for
each patient receiving narcotic medication.

PARTIALLY USED CONTROLLED

NON-NARCOTIC MEDICATION
FROM MULTI-DOSE VIAL
Can

be kept in the ward until the expiry of

its viability.
The remaining medication is discarded and
appropriately documented in the green card.
The vial is discarded appropriately.

 Partially

used controlled/narcotic medications

from a multi-dose bottle (syrup) must be
returned to the Pharmacy within the time limit
stipulated by the Pharmacy Department:
Three months after the opening of the bottle
in the ward, as per manufacturers expiry date
if less than three months or according to the
date specified by the pharmacy.

WHEN A PRESCRIBED CONTROLLED

MEDICATION AMPOULE IS OPENED
AND MEDICATION IS THEN NOT USED
A Pharmacy incident report must be
completed by the prescribing physician.
The pharmacist, head nurse, the ADON and
/or nursing supervisor on duty must be
informed accordingly.
The pharmacy incident report that is
appropriately signed should be sent to the
Pharmacy.

WASTAGE DUE TO ACCIDENTAL

DAMAGE OF CONTROLLED
MEDICATION
In

the event of accidental damage, ADON,

Supervisor, and the Pharmacist must be
informed immediately
Evidence of damage must be retained for
inspection by the pharmacist.

 The

original copy of the Pharmacy incident

report together with the broken ampoules and /or
containers must be sent back to the pharmacy.
A copy of E-OVR must be submitted by the
ADON or supervisor to the Nursing
Administration.

THE EVENT OF ANY DISCREPANCY IN

ACCOUNTING FOR THE MEDICATIONS
The

nurse in charge of controlled medications

must
immediately
inform
the
head
nurse4,ADON,or supervisor accordingly
The Head Nurse /designee should ensure that no
nurse leaves the unit without permission from the
ADON or Supervisor.
The Head Nurse/designee must initiate the
following actions:

Undertake a thorough check for the unaccounted

medication using the controlled drug card and controlled
drug prescription form 0220 as appropriate. If the
discrepancy persists, the ADON and/ or supervisor
should be informed immediately.
The ADON and/or supervisor must further investigate
the incident and accordingly inform the Directors of
Nursing and Pharmacy
Both , a pharmacy and a general incident report, should
be completed appropriately by designated narcotic nurse.

 After

having checked relevant documents and the

empty narcotic ampoules, the designated
registered nurse and the pharmacist should sign
the medication order book.
The used controlled order book (Red Book) should
be returned to the pharmacy for review, clearance
and appropriate disposal.

RETURN OF CONTROLLED DRUGS

CARDS AND ORDER BOOK (RED)
Once

a batch of medications issued on one particular

controlled medication card are used or no longer
required on the unit, the designated registered nurse
should ensure that the:
Controlled medication card has been appropriately
completed and signed.
Narcotic
prescriptions no. 0220 have been
appropriately completed and signed.
Empty narcotic ampoules are accurately accounted

THE DESIGNATED NURSE AFTER CHECKING

THE ABOVE ITEMS ACCURATELY WILL
ENSURE THE FOLLOWING ARE RETURNED TO
THE PHARMACY
Controlled

medication card
Controlled medication order book
Controlled prescription form 0220
Empty Narcotic Ampules

 After

HAVING CHECKED RELEVANT

DOCUMENTS AND THE EMPTY NARCOTIC
AMPOULES, THE DESIGNATED REGISTERED
NURSE AND THE PHARMACIST SHOULD SIGN
THE MEDICATION ORDER BOOK
(NARCOTIC/MEDICATION).THE USED
CONTROLLED ORDER BOOK (RED BOOK)
SHOULD BE RETURNED TO THE PHARMACY
FOR REVIEW, CLEARANCE AND APPROPRIATE
DISPOSAL.

IN ADMINISTRATION OF INTRAVENOUS
INFUSION OF CONTROLLED/ NARCOTIC
MEDICATIONS, THE REGISTERED NURSE
SHOULD ENSURE THE FOLLOWING:

A completed physician order is obtained and

Form 0220 is appropriately completed for each
infusion dose. The completed physician order
and Form 0220 are both sent to the pharmacy as
appropriate.

 The

nurse collecting the medication must

always check the name, strength, quantity,
expiry date, and any discrepancies in the
presence of the pharmacist prior to signing the
controlled/narcotic medication card and the
order book.
On arrival to the ward/unit, the medication
details must be re-checked by the collecting
nurse and another registered nurse and then
appropriately documented in the order book.

 After

the infusion of the medication, the

following should be returned to the
Pharmacy:
Completed form 0220
Controlled medication card and order book

 Partially

used narcotic/controlled medication

in piggy back or a syringe pump must be
returned to the Pharmacy within 24 hours
during the weekdays, or on the first working
day following the weekend with appropriate
documentation.

 When

a controlled/narcotic IV medication bag is

prepared and not used:
A Pharmacy incident report must be completed
by the prescribing physician.
The pharmacist, the Head Nurse, the ADON and
/or the supervisor on duty must be informed
accordingly.
A copy of the Pharmacy incident report (0372)
that is appropriately signed should be sent to the
Nursing Administration while the original copy
is sent to the Pharmacy.

ADMINISTRATION OF MINI AND

MULTI-DOSE CONTROLLED
MEDICATIONS
When a patient is prescribed a small dose of
controlled medication, the first dose is
administered from the ward stock.
For consecutive doses, the physicians order,
together with appropriate documentation,
should be sent to the Pharmacy for
preparation of the controlled medications

 The

nurse collecting the medications must

always check the strength, quantity, expiry
date and any discrepancies relating to each
individual order in the presence of the
pharmacist prior to signing the controlled
medication card and the order book

REMEMBER:
The Ministry of Health of the Kingdom of
Saudi Arabia would like to remind all staff
of the severe penalties pertaining to any
discrepancies regarding the handling and
the use of controlled medications

Nursing ADMINISTRATION ClinicaL

Policy #: NUR-CLIPP-035

Nursing IPPS revised2010

LIST OF CONTROLLED NARCOTICS AND CONTROLLED NON- NARCOTICS

RIGHTS OF GIVING MEDICATIONS