Commissioner's Directive

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Policy number and title:

COMMISSIONER'S DIRECTIVE 805 - ADMINISTRATION OF MEDICATION

What is the purpose of this Policy Bulletin?

The purpose of this Policy Bulletin is to provide specific direction regarding institutional wardstock, including but not limited to narcotics and other controlled drugs.

When does this Policy Bulletin come into effect?

Sections pertaining to procurement, content and amounts of wardstock come into effect September 1, 2009. Sections pertaining to storage are effective upon installation of approved safes. In the interim, all narcotics and controlled drugs must be double locked.

What medications can be kept as wardstock?

Medications that are non-formulary and/or for which there are no patient specific orders will not be kept as wardstock. Medications required for the Emergency Medical Directives are an exception.

Is the amount of wardstock limited?

The quantity of wardstock will not exceed a one week supply and should be further restricted to coincide with pharmacy access and delivery schedules.

How do institutions obtain wardstock?

All wardstock must be ordered from the regional or approved community pharmacy. Wardstock must not be ordered from multiple pharmacies.

If medications, that would otherwise be considered wardstock, are ordered on an emergency basis from other than the regular pharmacy, the regular pharmacy will be notified in writing of the medication(s) received and amounts.

Once an inmate has been transferred or released, any remaining patient specific medications will be returned to the regional or community pharmacy. These medications will not be entered into wardstock.

Storage in satellite pharmacies

Narcotics and controlled drugs shall be locked in a safe within the room designated as the institutional pharmacy. While these medications may be administered from satellite pharmacies, they will not be stored in satellite pharmacies.

Refrigeration

Narcotics and controlled drugs requiring refrigeration must be kept in a locked refrigerator. Methadone will be stored in the safe, not in refrigerators.

Audits

Chiefs of Health Services will conduct monthly audits of institutional wardstock to ensure the above requirements are met.

Revision of CD 805 - Administration of Medication

CD 805 - Administration of Medication is currently under revision. Specific direction regarding institutional wardstock will be incorporated into the revised version.

Accountabilities?

• Regional Pharmacists
• Managers of Clinical Services
• Chiefs of Health Services
• Nursing staff

Who will be affected by this Policy Bulletin?

All institutional staff responsible for the maintenance of institutional wardstock.

Expected cost?

Costs will be incurred for the procurement of approved safes for the storage of narcotics and other controlled drugs.

Contact:

• Joanne Barton
• A/Project Officer, Clinical Services
• 613-947-6445
• joanne.barton@csc-scc.gc.ca