Pharmacy Policy Manual
Policy #: 7.4
Title: Controlled Substance Discrepancy
I. PURPOSE: To establish a policy and procedure for the documentation of controlled
II. POLICY: The department of pharmacy shall be responsible for documenting any
discrepancy that occurs during the distribution, inventory maintenance or replacement of
controlled substances at UWHC
III. FORMS: Controlled Substance Discrepancy Report (# 9039)
A. Initiation of discrepancy report form.
1. The pharmacist/pharmacy technician/nurse will initiate a controlled substance
discrepancy report form when a discrepancy is discovered during their shift.
2. Discrepancies will be investigated by the pharmacy technician or pharmacist to whom
the even is reported.
B. A discrepancy has occurred when:
1. An item is missing or extra, or needs to be wasted.
2. An established procedure has not been followed and documentation of the event is
3. Something suspicious has occurred concerning controlled substance distribution and
documentation of the event is desired.
C. The names of the potential personnel involved in the error should be indicated on the
report. Potential personnel involved may include staff that worked on the shift prior to or
during the shift of the event and in some way may have contributed to the event.
D. All reports will be reviewed by the Pharmacy Manager, Business and follow up action
taken as needed.
A. AUTHORED BY: Dave Musa
B. COMMITTEE APPROVAL BY: None
Approved By: ____________________________
Director of Pharmacy Services