Table 1

Activities for the governance of controlled drugs (CDs) in hospital wards

CD governance activityDescription
Safekeeping/Controlling access
  • CDs (including those owned by patients) stored separately from other medications, in a cabinet or metal safe, kept locked when not in use.

  • Access to CD cabinets’ keys strictly controlled.

  • Access to CDs restricted to staff members authorised to administer them.

  • Accesses witnessed by a staff member.

  • Expired, unusable or unwanted CDs stored in the safe pending destruction.

Documenting transactions
  • Records kept of CD transactions in a drug register.

  • Records of transactions signed by two staff members present during the activity (eg, nurse and witness).

  • Transactions recorded in the CD register included: removal and replacing of CDs from the storage unit; discarding any unused portion of the CD and destruction of CDs.

  • Audits of CDs in stock performed to confirm records are meeting policy requirements and to detect any possible misappropriation.

  • The recorded CDs balance checked daily against the physical balance in the cabinet and safe, by a registered nurse/midwife with a witness and documented in the register.

  • Expired, unusable or unwanted CDs, pending destruction, are included in the routine stock checks.

Reporting and investigating
  • CDs discrepancies recorded and reported to the hospital management and authorities.

  • Investigations conducted to explain the discrepancies.