Implementing

Policies and
Procedures

The basic purpose of establishing

systems, processes and guiding
them in policies and procedures is
to implement them well.

Failing to implement, is wasting

time, money, effort and other
resources.

Policy Implementation
It is encouraged to have a minimum
of 1 month between the date of
issue and the date of effect for
orientation and in-service training

Policy Implementation

Implementation process involves a

period of three (3) months to give time
for

distribution,
familiarization,
actual practice and
monitoring

Policy Implementation
All

the hospital staff shall sign in the

Acknowledgement Sheet to signify that they
have read and understood the Policies and
Procedures (Hospital Wide, Departmental,
Safety, Infection Control, etc.).

Original Copy filed as page 3 in the Manual kept

in every department

Acknowledgement Sheet
HOSPITALWIDE POLICIES AND PROCEDURE
STAFF ACKNOWLEDGEMENT SHEET
I, the undersigned, have read and understood the contents of this Hospitalwide Policy and Procedure Manual.

NAME

Note:

ID NO.

SIGNATURE

DATE

Original Copy in the Hospital Wide Policies and Procedure Manual.

Duplicate Copy to be forwarded to the Total Quality Management
(TQM) Department.

 Accrediting

bodies require that

policies are:
Documented
Approved
Communicated/educated
Implemented

Methods

Distribution of the policy

Departmental meetings announcements
Workshops
Presentations and discussions
Posting of process flowchart
Competence checks (periodically)
Quiz and questions for the staff
Staff attitude
Staff adherence

Working /Departmental/
Multidisciplinary policies
Processes
Guidelines
Daily

work/ services

It costs organizations a lot of time,

money and effort to work on
policies and procedures and
establish systems and processes.

Not living those policies may lead

to unsafe patient care as well as
jeopardize the wellbeing of the
staff.

MPP- PH 034 (3)

HANDLING OF
NARCOTICS AND
CONTROLLED
MEDICATIONS

CBAHI
STANDARDS

PH. 45 There is a system for handling

Narcotics and Psychotropic Drugs (Controlled
Drugs) in accordance with MOH regulations
and includes but is not limited to:

PH.45.1
There is a written policy and
procedure for
handling
narcotics and
psychotropics.
PH.45.2
Receiving, storing and dispensing
controlled drugs by the pharmacy.
PH.45.3
Keeping controlled drugs behind
steel doors with double locks.
PH.45.4
Keeping limited floor stock supply in
a double door, double locked cabinet.

Why we have this

standard?

The Ministry of Health (MOH) determines the

procedures for procurement, storage and dispensing
of narcotics and psychotropics. Such rules must be
respected. Provision of a uniform steel cabinet with
double locks in all patient care areas where small
stock are allowed guarantees stock safety. Stock
access is limited to few people. On the other hand,
main pharmacy supplies are kept behind steel door
in a vault or large steel cabinets. Access is limited to
narcotic pharmacist in-charge.

PH.46 There is a system for auditing

Narcotics and Psychotropic Drugs in
accordance with MOH regulations:

PH.46.1 Auditing every shift in the pharmacy.

PH.46.2 Auditing every shift in each nursing unit.
PH.46.3 Maintaining proper documentation of
drug count and accountability in the pharmacy.
PH.46.4 Maintaining proper documentation of
drug count & accountability in each nursing unit.
PH.46.5 Maintaining proper documentation of
empty containers of narcotics.
PH.46.6 Evidence of proper disposal of unused
portion of an ampoule or a tablet.

Why we have this

standard?
In

order to ensure accuracy of count,

a system for auditing between shifts
is required by the ministry of health.
Maintenance
of
proper
documentation in presence of a
witness minimizes the opportunity
for misuse or abuse of narcotics and
psychotropics.

PH.47 There is a system for Prescribing

Narcotics and Psychotropic Drugs (Controlled
Drugs) in accordance with MOH regulations
and includes but is not limited to:

PH.47.1Using the MOH approved prescriptions.

PH.47.2 Not allowing physicians to prescribe
controlled drugs for self or family members.
PH.47.3
Allowing only clinical privileged
physicians to prescribe.
PH.47.4
Allowing only psychiatrists and
specialists to prescribe psychotropics (except
during emergency).
PH.47.5 Not allowing injectable narcotics and
controlled drugs for outpatients.

Why we have this standard?

Rules and regulation made by the

ministry of health (MOH) are to be
respected. Only approved prescription
format is used for prescribing.
Prescribing privileges and supply
quantities are clearly stated in the
MOH narcotic manual. Injectable
drugs in this category are not allowed
for take home by the patient.

PURPOSE:

To comply with Saudi Arab Government rules and regulations

governing importation and distribution of narcotic and controlled
drugs.
To establish specific policy and guideline in order to maintain
adequate control of the distribution, safeguarding and
storage of all narcotic and controlled drugs.
To define each responsibility of the hospital personnel
involve in prescribing, dispensing, administering, storing, and
record-keeping of all narcotic and controlled drugs.
To implement a system for auditing between shifts as
required by the Ministry of Health that will ensure accuracy
of count.
Minimize the opportunity for misuse or abuse of narcotics
and psychotropics by maintaining proper documentation in
presence of a witness.

DEFINITION:
Narcotic Drug: A drug that produces
sleep or stupor, simultaneously relieving
pain, such as opium, morphine, etc that
leads to increasing tolerance and
physiological dependence.
Controlled Drug: A controlled drug is one
whose use and distribution is tightly
controlled because of its abuse potential
or risk. Prohibited drug is classified as
controlled drug.

RESPONSIBILITY:
The

Narcotic In charge is solely responsible

for the management of narcotic and
controlled medications in pharmacy.
The Head Nurse is responsible for handling
the above-mentioned drugs in the nursing
care areas.
The Pharmacy staff, when narcotic-in-charge
is off-duty, is responsible for dispensing.
The medical staff is responsible for adhering
narcotic and controlled policy in terms of
drug ordering.

POLICY:
Only one drug is allowed per prescription.
Prescription must be Indelible.
No verbal or telephone order is allowed in giving narcotic
medication.
Narcotic & Prohibited drugs must be kept in a safe and
double-locked cabinet.
Only the Pharmacy Narcotic In charge or his designate (on
his absence) can supply, dispense drugs, and handle safe
keys.
Strict compliance in handling regulated and prohibited
drugs is mandatory in order to secure patients from its
abusive and addictive effect.

PROCEDURE:
Stocking/

storing

Pharmacy stock is under the control of

narcotic-in-charge. Stocks must be in
secured custody and properly stored
according to manufacturers storage
recommendations.
Ward stock is under the safeguard of the
head nurse or charge nurse on her
absence. Ward shall carry only limited
stocking, according to their needs.

Labeling and monitoring expiring drugs

Complete drug name and its strength must be readable.
It shall carry its expiration date both for prepared or ready to use
drug.
Nearly expired drug, at least 2 months before its due date must
be notified to the Pharmacy Director particularly if the present
amount may not be consumed by the hospital from the estimated
consumption. The Pharmacy Director is responsible for informing
the Central Medical Store for the management of expiring drug.
Dispensing and supplying must conform to the pharmaceutical
practice of Early Expirations; First-in, First-out and when
necessary, a later expiration date batch in the wards should be
replaced with batch earlier to expire by the narcotic-in-charge.
Destruction of the expired drug shall be done only after approval
from the Central Medical Store. Proof of approval must be kept
and registration adjustment must be done correctly.

 Dispensing

and prescription guidelines

Only the approved prescription and drug name

must be used.
Only one drug per prescription is allowed.
Only oral preparations are dispensed to the
outpatients. Injection is strictly for inpatients only.
The rules and regulations for prescription
dispensing in the hospital must be adhered to:
Prescription without patients complete data and
diagnosis shall not be served.

The controlled drugs in the hospital are

classified according to the
prescription format as follows:
Prohibited Drugs: The prohibited drugs are
prescribed in the approved Prohibited Prescription
which contains five sections.
The first section contains the patient data to be
filled by the nurse.
The doctor shall fill the second and third sections.
The fourth section is for the dispensing pharmacist
and/or the patient or his relative.
The prescription must be written with blue pen, legible
and any cancellation invalidates it.

For In-Patients: Drugs for the in-patients are

directly under the supervision of the Narcotic in
charge. Borrower slip may be issued for interdepartmental transfer of any scheduled drugs.
This must be endorsed by the Head Nurse. The
drug concerned must be replaced soon and the
borrower slip cancelled thereafter. Only clinical
privileged physicians are allowed to prescribe
Narcotic and Psychotropic (Controlled) Drugs.

For
Out-Patients:
Syrup
(Phenobarbitone): may be prescribed for
up to 15 days maximum per consultation
as stated on its stability. Tablets and oral
drops: May be prescribed for up to one
month. Up to 7 days medication may be
issued to patients attending the ER when
necessary.

Inventory
Adequate stock level of the individual drugs must be ensured by
constant liaison with the Narcotic Pharmacy and the Drug store.
On- call stocks must be monitored by the in-charge and the
head of the Dept must be informed of any discrepancy.
Routine review of drug stock level must be done and the head of
the Department informed of any inadequacy.
Responsibility must be endorsed to another Pharmacist in writing
in case of absence from duty for whatever reason with the
knowledge of the head of the Dept.
An accurate monthly inventory of drugs shall be carried out and
meticulous record of all the receiving and issuing shall be
maintained.

Record Keeping
Proper daily documentation shall be carried out in line with the
specifications in the MOH and KSA drug schedule.
The established routine in the hospital regarding the individual drug
control and statistics must be adhered to:
Recording prescription daily in the register for daily supply.
Providing quarterly statistics return to the MOH for the respective
drugs.
Monthly statistics return for the single normal prescription items as
required by the MOH
Proper documentation of empty containers, unused portion of an
ampoule or tablet of a narcotic /controlled drug.
Proper monthly filing of the prescriptions in a safe place. Narcotic
prescriptions and register to be kept for 10 years, controlled
prescriptions for 2 years and register shall be kept safe for a period
of 5 years.

Narcotic and Controlled Drugs In The Wards:

Few amounts of controlled drugs are kept in each ward as per

consumption pattern. They are to be kept in the steel vault provided.
The head nurse is responsible for the safety and proper
documentation for the drugs under her care.
Prescriptions for narcotic and controlled drugs are made by the
attending doctor.
The head nurse or shift-in-charge supplies the drug to the nurse
assigned to the particular patient as per the doctors order. The
appropriate documentation should be entered immediately in the
register.
Prescription shall be replaced via the head nurse or her designate
who shall verify the physicians order and consumption endorsement
in the ward before bringing the prescription to the pharmacy. The
replaced quantity shall be returned to the ward by the head nurse or
her designate after filling from the pharmacy.

Rules & Regulations For Doctors &

Nurses regarding Narcotic &
Prohibited Drugs
Ward stock should be under the responsibility of the Head
Nurse:
Label: Expiration dates must be present for all drugs. Nearly
expiring drugs, specifically two months before its expiry date
must be notified to narcotic-in-charge.
Narcotic Checklist: After endorsement it must be signed together by
endorser and receiver. If there is any discrepancy, it must be written in
the remarks column and the narcotic in- charge or the nursing supervisor
should be informed.
Narcotic Register: Amount of drugs supplied, borrowed, given and
discarded must be written clearly in the register. No liquid eraser is
allowed. Discarded portion must be written in red ink.
Safe Keys: Safe keys must be endorsed to the person receiving the
endorsement and should be always available in the ward. Only the Head
nurse or the shift- incharge or her designate can handle the keys in her
absence.

Prescriptions:
All prescriptions must be completely and properly filled up
and signed by the doctor.
Each prescription must be written in un-erasable ink.
Only one item is allowed per prescription.
The prescribed amount and strength should be written
in the prescription.
Any alterations of the patients name, drug name,
dosage or duration invalidate the prescription. This
should be cancelled and another prescription issued.
Any alterations of the time, date, age, nationality, chart
no and diagnosis should be countersigned by the
prescribing doctor.

 In case of cancellation the cause must be

indicated and signed by the Narcotic- In-Charge
and Medical Director. (cancellation by narcotic-incharge only)
Narcotic Drugs: In pre-medication the time
and date to be written by the Medication
nurse. In narcotic prescription only stat dose
allowed.
Prohibited Drugs: Four copies of the
prescription to be written.

The prescription is divided into 5 sections.

Patients data to be written by the nurse and
the diagnosis by the doctor. Drug name, dose,
frequency route of administration to be written
by the doctor. For take home medications only
relatives of patient are allowed to receive the
prescribed medicines with ID. After giving the
medication to the nurse, the head nurse and
the doctor must write their names with
signatures

Only one item is allowed per

prescription.
In Patients: The prescription for tablet and injection shall
be for 3 days only (regular dose).For stat dose one day
only. Syrup phenobarbitone can be prescribed up to 15
days.
Out Patients: Tablets can be prescribed up to 30 days only. In
ER prescriptions 7 days medication can be prescribed. It must
be written in the patients file. No injectable drug will be issued
to out-patients. Syrups-15days maximum per consultation.
Prescription cannot be filled in after 7 days.
Controlled Drugs: Should be prescribed in double normal
prescription. Date, time started, due and total should be written
in the Prescription.

Administration of Drugs: Prior to administration, prescription,

medication sheet and the order in physicians notes must
be completed by prescribing doctor.
Narcotic Drugs
The nurse should administer the drug in the presence of
the prescribing doctor and under his/her supervision,
except for pre-medication.
The amount of drug left over from the prescribed amount will be
discarded immediately under the supervision of the prescribing
doctor who will sign with the administering nurse.
In pre-medication the drug should be given under the
supervision of head nurse and another nurse in the ward. They
should sign together for the destruction of the remaining
quantity of drug, if the whole ampoule was not used.
Narcotic drugs are not dispensed to outpatients.
Empty ampoules should be kept for replacement.

Prohibited Drugs:

Date ordered, frequency, how many days

it will be given (max 3) should be written
by the doctor on the medication sheet.
Injectable medication will remain up to 8
hrs. Any remaining amount can be
shared with other patients within the
ward.

 Supplied Form Of Prohibited & Controlled

Drugs
The nurse who has started the first dose
should write the date and time started, the
amount given and signs thereafter. And
likewise for the last dose, but the total
medication consumed must be included.
Shared medication to other patients within
the ward must also be written clearly.

 Borrowers slip: Used in borrowing prescribed

medications not available within the ward.
It must be signed by the head nurse during duty hrs or by
the charge nurse and on following morning it must be
countersigned by the head nurse.

Broken Ampoule: Immediately inform the narcotic incharge (during duty hrs) and nursing supervisor. It
should be left untouched until the arrival of the
narcotic- in-charge or the nursing supervisor to
witness the incident. It should be witnessed by the
prescribing doctor. Incident report to be written at
once to be signed by the witnesses.

Missing Ampoule: The narcotic-in-charge and the

head nurse should be informed immediately. The
incoming nurse who will receive endorsement should
write in the Narcotic Checklist the missing ampoule.
Refused Medication Or Opened Ampoule Not Used: Inform
the head nurse. If off-duty inform the nursing supervisor.
Inform all the wards regarding the unused ampoule and
keep the medicine for 8 hrs. If not used within 8 hrs, the
doctor on duty or the prescribing doctor should write the
reason in the patients file. Prescription must be made and
medicine should be discarded (narcotic medicine can't be
kept for 8 hrs).

FORMS & EQUIPMENT:

Prescription Form for Narcotic Drugs

Prescription Form for Controlled Drugs
Quarterly Report of Narcotic Drug
Quarterly Report of Prohibited Drug
Medication Chart for Given & Discarded Amount of Narcotic Drug
Medication Chart for Given & Discarded Amount of Prohibited &
Controlled Drug
Borrower's Slip
Ward Round for Narcotic Drug Inspection Form
Special Anaesthetic Request Form
Narcotic Prescription Log-in Sheet
Prohibited Prescription Log-in Sheet
Narcotic Checklist Form
Register Form for Administered Narcotic & Controlled Drug
Register Form for Used Prohibited & Controlled Drug
Register Form for Daily Supply of Narcotic Drug
Narcotic Empty Ampoule Destructed Form