1. Countable Controlled Substances
Medication Education Module 1
Countable Controlled Substances
****Trainer Preparation
Copies of Countable Exercises [you can use your own count book pages or let staff know because of the count book you use, the pages will not look exactly the same]
Consider using transparencies with dry erase marker with an overhead projector and have staff take turns completing the countable exercises and discuss
For Trainer:
PowerPoint “Notes” pages
Countable Substance Curriculum Trainer Guide
Countable Substance Quiz Answer sheet
For Staff:
PowerPoint handout
Print p. 2 “Objectives” to test staff knowledge before & after the training.
(Use as your training documentation.)
Corresponding MAP Policies 10-2, 10-3, 10-4, 10-8
Countable Substance Staff Handout
Countable Substance Quiz
Count Performance Checklist
Countable Substance DPH examples
Countable controlled substances are sometimes referred to as narcotics.
Tell staff what the pharmacy service you use does to “identify” the package of a countable substance so staff knows which are countable.

2. Objectives 1. Why count them so often? 2. Why the extra documentation?
3. Why the special packaging?
What I know about countable medication before the training: 1. 2. 3. 4.
What I learned about countable medication after the training:
4. Why the extra security?

3. Countable Substances Higher incidence of abuse or addiction
Count requirement
Each time staff changes, 2 Certified staff count together
Documentation requiring 2 signatures
When beginning a new count sheet
Adding a refill onto a count sheet
Transferring from
bottom of old page/top of new
an old count book to a new count book
Disposal
The purpose of requiring 2 certified staff signatures is to decrease the opportunity for diversion (theft).

4. The Schedules Schedule I Schedule II Schedule III Schedule IV
Schedule V
Schedule VI
Historical Background
Schedule Definitions
MAP Program Requirements
Summarize the countable substance staff handout or divide in groups and have staff read, appoint a spokesperson and explain about the historical background, different schedules and MAP program requirements or just go through PowerPoint slides.
The federal government categorized prescription meds into “schedules” according to the meds potential for abuse or addiction.
Schedule I meds have the highest potential for abuse and currently have no accepted medical use in the United States; examples are heroin and LSD.

5. Schedules In the Medication Administration Program (MAP)
Any prescription meds in
Schedules II-V are categorized as
Countable Controlled Substances
Meds categorized in schedules II-V also have a potential for abuse.
In addition to keeping documentation of all prescription meds ordered and received, countable substances require entry into a Countable Controlled Substances book.

6. Schedules
Schedule VI
All prescription meds not included in schedules II-V
Examples
Penicillin
Dilantin
Schedule VI meds are not required to be added into a count book.

7. Schedule VI
Although not required, DPH strongly recommends adding to the count
Fioricet
Gabapentin (Neurontin)
Fioricet is used to treat tension headaches.
Gabapentin (Neurontin) may be used for seizures.

8. Why Count and Record? Protect Safety of Individuals
Certified staff from being accused of mishandling or misusing
This slide is self explanatory.

9. Why Count and Record?
Assist Certified staff in adhering to laws, regulations and policies
If countable substances or prescriptions are taken by a Certified staff an investigation will follow with possible police involvement
This slide explains why it is so important to always follow the guidelines.

10. Tamper Resistant Packaging
Purpose
To minimize the chance that the medication inside is replaced with another
Blister packaging is the most common. Examples of other tamper resistant packing are OPUS (cassettes) and Opti-pak (unit dose).
You could also review here what staff are to do if the med inside seems to be tampered with. (Call the MAP Consultant if the med is due to be given and it is the only package, if not contact the Supervisor first to report.)
If you participate in “blister pack monitoring” [not a requirement] you could mention here that staff ONLY on the backside of the package initial, date and time each tablet removed and that you monitor periodically to ensure all meds are given as ordered.

11. Security Access to med storage area is limited
A Certified staff is assigned the task of med administration
Only the assigned Certified staff should have access to the med storage area
One duplicate key in possession of administrative staff.

12. Security-Inventory
The Certified staff assigned to give meds is responsible for the inventory (supply) during their assigned shift
Must
Count at beginning and end of shift
Keep key with Certified staff assigned as long as they are in program

13. Security-Inventory
If there will be no Certified staff home during the day, the keys must be kept locked in the home
Realtor type combination locked box
Count must be done before placing keys in the locked box and after removing keys from the locked box
Only MAP Certified staff know the combination to the locked box.

14. Security-Inventory
Whenever there are 2 Certified staff available there must always be a 2 person count
Conducting a 2 person count once every 24 hours is an “exception” to MAP policy
If there is no one else available a single person count should be done
The count signature page should indicate it was a “single person count”
When the count signature page has a staff who has signed their name and written “single person count”, that means they were not working with another MAP Certified staff to witness that the count was correct.

15. Security-Inventory Due to staffing patterns
The “exception” becomes the “norm” when the typical staffing pattern is 1 Certified staff throughout a 24 hour period
A Supervisor will ensure that at least once every 24 hours 2 MAP Certified staff are available to conduct a 2 person count together
This is the only time it is permissible to count only once every 24 hours with 2 MAP Certified staff.
The ONLY time a single person count should be done is when there are no other MAP Certified staff on duty to count with.
In this case in between the 2 person count should be single person counts.

16. Security-Inventory
Only Certified staff who may be assigned to administer meds should know the locked box code
The combination should be changed when a Certified staff is no longer working at a site or staff is no longer Certified (such as did not pass recertification)
These are examples of how often the combination should be changed.

17. Security-Inventory
Whenever the Certified staff assignment to give meds changes
Keys are passed
A count must be done
This is how often a count should be done.

18. Security Count must be done
Shoulder to shoulder with the off-going Certified staff and the on-coming Certified staff
Countable meds must be counted every time the shift/staff changes
Ideally with a staff coming on and another staff who is leaving
If that is not possible, count with another MAP Certified staff working on the same shift

19. Security-Inventory On-coming Certified staff has blister packs
Off-going Certified staff has count book
Leads the count using the index
Consider actually counting with a staff here to demonstrate.
Counting should be done using the index.

20. Security-Inventory During the count process
Both staff look at blister pack and count book
Full legal signatures on shift count verification page

21. Count Book Must Be bound
Have an index and shift count signature verification pages
Preprinted page numbers
Have pages that cannot be removed
The next 3 slides cover the basics of the count book itself.
Each count book is “numbered” somewhere in the front.
If the pages become loose staff should notify a Supervisor so that another book can be obtained as quickly as possible.

22. Index Must be kept accurate and up to date
Assigned Certified staff can add a countable substance into the index
The Site Supervisor (or designated back up) is responsible for removing the Countable from the index
Examples of when the supervisor would sign in index as removing from count would be when a med is discontinued and disposed of.
If you as a Supervisor highlight a row in the count book index to indicate either the med is no longer on count or has been moved to the next available index row, explain this process to staff if needed.
Lines on an index or pages of an index should NEVER be skipped.

23. Security-Inventory
When entering a countable in the book or transferring to a new page the assigned Certified staff should complete the Heading section of the next available page
Do not skip pages
The staff giving meds who uses the last line on a count sheet is the one who transfers the information to the next available count sheet and updates the index.

24. Sample Index Page
The index page at the beginning of a count book identifies the pages that are currently in use. It must be kept accurate and up to date. According to this index, there are 3 count sheet pages currently in use.
Looking at this index, you know Sarah Brown’s Phenobarbital is no longer in the doubled locked area to count because Karen Mason (Supervisor) signed as removing it from the count. If the med was discontinued, it would have stayed on count and double locked until disposed of. Only after its disposal (following the guidelines) would a supervisor sign as ”Responsible for Removing Medication from Count”.
Mike Stone has Ativan 1mg tabs to be counted on p. 5 (because p. 2 became full.)
The index must be updated when transferring information from an old count page to a new count page.
When the 4 boxes next to Joseph Smith’s Ativan were full, a Supervisor wrote “see below” with their initials to indicate his Ativan had started on a new row in the index. Joseph Smith’s Ativan 0.5mg is currently found on page 11.
William Mitchell has Percocet to be counted on page 8.

25. Count Sheet Scenario 1
Page 11
Look at the first yr entry – This is an example of when page 10 of the count book was ”full”, the information was transferred ontto the next available page. Karen and Lisa’s signature would be at the bottom of the ”full” page [page 10] also.
12/20/yr 11:00 am entry – this is an example of meds had been re-ordered and the refill blister package is added to the existing supply. When added, the MAP Certified staff was working alone.
12/20/yr 3:00 pm entry - Hours later when the second MAP Certified staff came in, that staff verified the amount received from the pharmacy and documented.

26. Count Sheet Scenario 2
Page 11
Scenario 2 demonstrates when the count is correct in a blister pack but the math documentation in the count book is incorrect.
A supervisor will look at the incorrect documentation and counsel the staff who subtracted incorrectly to be more cautious.
12/20/yr 7am Math on 12/19/yr 8p entry is incorrect. Karen Mason, Supervisor notified. Correct count is 6 left Reggie Newton

27. Count Sheet Scenario 3
Page 11
Scenario 3 is an example of the count being correct but the staff forgot to document the med when it was removed from the package.
A “late entry” should be documented by the staff who gave the med but forgot to document.
No spaces should be skipped for the staff to “go back” and subtract.
12/20/yr 7:45p Morning dose not subtracted when removed. K. Mason notified. Lisa Long
12/21/yr 6a Late entry On 12/20/yr 8a med was given and not documented at that time. Reggie Newton

28. Count Sheet Scenario 4
Page 11
Scenario 4 are examples of how to correct a documentation errors in the count book.
Lisa wrote small enough and neat enough to be able to correct on the same line.
Reggie’s writing is bigger and he decided to mark a single line, error and initial through the entire row and rewrite the information.
Error LL
Error RN

29. Questions
With countable meds, it is important to always write a story in the count book (no matter how many lines it takes) to explain anything out of the ordinary that happens.
At this point consider having staff go over the DPH handout examples, take the quiz and/or complete the count performance checklist.

30. Resources Beth Steele, RN Fidelity House, Countable Exercises
Mary Rota, RN DPH Clinical Reviewer,
MAP Trainer PowerPoint Presentation
MAP Curriculum
MAP Policy Manual