As part of our ongoing efforts to refine our Controlled Substances (CS) Handling Policy, we’ve encountered a particular challenge: ensuring accurate tracking and documentation of controlled substances during off-floor procedures or when given to another for future use.

Scenario 1: Fentanyl Use in Imaging
An RN may take a vial of fentanyl to imaging for a procedure as there is not ADS in that area at present, administer a partial dose while off the floor, and then return to the unit. The challenge arises in documenting the waste, as there is no witness to the entire process, and no way to ensure the remaining volume hasn't been altered.

Scenario 2: Shared Administration of a Single Vial
An RN drawing up a vial of fentanyl before a procedure, but the medication ends up being administered by two different individuals.

We are currently exploring the best ways to recommend appropriate tracking and documentation in these situations to maintain compliance and ensure patient safety. Any advice, workflows or best practices you would be willing to share with my team?

Thank you!
Amy