Controlled substance medication safety rounds

BACKGROUND: Controlled substance diversion amid the opioid epidemic threatens patients, health care workers, organizations, and communities, underscoring the need for effective prevention and response strategies within health systems. PURPOSE: A 3-year performance improvement initiative at a large academic medical center was undertaken to enhance awareness of medication safety related to controlled substance (CS) chain of custody. This article describes the implementation of CS medication safety rounds (CSMSRs) across three phases, with a primary focus on Phase III (2023-2024). METHOD: Using a Plan-Do-Study-Act (PDSA) framework, a seven-member interdisciplinary team implemented CSMSRs in ambulatory clinics, pharmacies, inpatient nursing units, and procedural areas. Proactive on-site evaluations engaged nurses and provided real-time feedback, improving adherence to best practices and strengthening CS safety and accountability. RESULTS: Nurses reported appreciation for the in-person CSMSRs and the opportunity to engage in dialogue regarding their adherence to institutional policies, equipment management, education options, and meaningful staff support resources. CONCLUSION: CSMSRs provided a platform for open dialogue, anonymous feedback, psychological safety, and accountability in CS management. Continued rounds are expected to engage nurses in sustaining safe practices, advancing opioid stewardship, and strengthening a culture of patient and employee safety.