Suspected Theft / Loss of Controlled Substances

Implementation Date: 10/2021

Date of Last Revision: 3/21/2023

Next Review Due: 3/20/2025

 

Reviewed by VTH Administrative Team: 10/2021

Reviewed by VTH Board: N/A

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

This policy is to describe the process to be followed when a theft or loss of a controlled substance is suspected. This policy covers all controlled substances under the DEA licenses of the Hospital Director. All unaccounted for controlled substances must be investigated. If the cause cannot be readily determined, the loss must be reported to the DEA and BOP within 1 business day of discovering it. Once the investigation is complete, if theft or loss is determined, DEA Form 106 must be submitted. If the cause is found to not be associated 
with theft or loss then notifying the DEA and BOP of what was found is sufficient – no form 106 is needed.

Guidelines

• Dispensary staff monitors counts of all controlled substances on a regular basis and investigates any quantities below what is expected.
• If the cause is not readily determined, the Hospital Director is contacted about the issue and the problem is reported to the DEA and BOP. 
• Once the investigation is complete, a DEA Form 106 is submitted if necessary.

Procedure (if applicable)

1. When a controlled substance count is less than expected, the pharmacy coordinator will account for 0.05ml of hub loss per stick. 
2. If the missing volume is not covered by hub loss, the pharmacy coordinator will review the dispensation documentation since the last adjustment. This includes Cubex records and yellow log sheets. People involved in removing doses will be contacted, if necessary, for clarification.
3. If the error is still not found, the camera footage of the location where the controlled substance was removed from is reviewed by the pharmacy coordinator to see if the problem can be identified.
4. If the problem is still not clear, the pharmacy coordinator will contact the VTH hospital director to report the problem and present any facts that can be determined.
5. Once the problem has been discussed with the director, or after attempting to contact the director and delaying as long as possible during that first day, the pharmacy coordinator will report the loss to the DEA and BOP.
6. If diversion is suspected, the DEA will be asked to provide assistance in the investigation. 
7. Once the investigation is completed and the theft/loss/error is identified, a DEA Form 106 will be submitted if a theft or loss occurred.
8. Regardless of the outcome, processes will be evaluated to prevent future issues.

Definitions (if applicable)

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.