Narcotic Safety at Women’s College Hospital

By Becky Wright and Natalie Benninger

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Narcotics (or opioids) have been identified as high-alert medications and have a heightened risk of causing significant patient harm when they are used in error. Additionally, their common use in healthcare increases the potential for misuse or diversion in this setting. Therefore, ensuring safe and appropriate use and storage of these medications, particularly high dose formats, are effective strategies to minimize the risk of death or diversion and is a Required Organizational Practice of Accreditation Canada. Click here for the QTip.

Women’s College Hospital (WCH) prioritizes narcotic safety by providing a system that ensures safe storage, administration, wastage, and monitoring of narcotic and controlled substances. The following strategies have been implemented at WCH:

  1. Narcotic storage
    1. All narcotic and controlled drugs are stored in a double locked storage area.
    1. High dose narcotics (e.g., fentanyl ampoules or vials with total dose greater than 100 mcg per container, hydromorphone ampoules or vials with total dose greater than 2 mg, and morphine ampoules or vials with total dose greater than 15 mg) are not stocked in patient care areas, except Operating Rooms which implement storage safeguards. 
    1. Naloxone is available in all patient care areas which stock narcotic substances.
  • Standardized documentation and administration of narcotics 
    • Patient care areas with narcotics use a standardized Administration Record for Narcotics and Controlled Drugs to track received, returned, administered, and wasted narcotics.
    • All patient care areas use a unit-specific Narcotic and Controlled Drug Requisition Form to standardize products and limit the quantities of narcotics stored in each unit.
  • Narcotic wastage and disposal
    • Narcotic waste is disposed of in designated tamper-resistant pharmaceutical or sharps waste containers, which are regularly taken to off-site facility for incineration.
    • Wastage of all narcotic and controlled substances are witnessed and documented by two independent regulated health professionals, except in Operating Rooms due to time-sensitive nature of care.
  • Narcotic audits and monitoring
    • Narcotic counts occur in each patient care area at shift changes and/or end of day, and in Pharmacy twice weekly.
    • Any discrepancies in counts are reported to Health Canada within 10 days and an Incident Reporting Information System (IRIS) report is completed.
    • Random audits are conducted every 6 months for narcotic administration, ordering and receiving, returns, and delivery.

More information on safe use of Narcotic and Controlled Drugs at WCH may be found on the Narcotics and Controlled Drugs policy document.

For more information on Accreditation, visit the Accreditation Intranet Hub.