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SOP: Controlled Substance Count & Discrepancy Resolution

End-of-shift controlled substance count procedure and discrepancy resolution.

SOP: Controlled Substance Count & Discrepancy Resolution

Standard process for end-of-shift controlled substance counts and resolving discrepancies.

End-of-shift count

  • Two-person count at shift change; compare to eMAR and narc log.
  • Record totals and both initials.

Discrepancy steps

  1. Recount with a second verifier.
  2. Review prior 24h administrations and wastes.
  3. Check returns, holds, and destroyed meds.
  4. If unresolved, notify charge nurse and follow On-Call & Escalation Matrix.

Download: Count & Discrepancy Form (PDF)

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