A system of drug distribution for controlled substances in a hospital operating room is described. Problems in accountability for and accessibility to controlled substances distributed by a floor stock method led to the new system. Small, lockable narcotic cases contain a sufficient quantity of Valium, Innovar, ans Sublimaze for one shift. Each nurse anesthetist signs out a narcotic case from the pharmacy at the beginning of the shift and is responsible for its contents until it is returned to the pharmacy at the end of the shift. Administration records are dept by the nurse anesthetist. A discrepancy in the count results in an incident report automatically and an investigation. The system has improved the drug distribution process in our operating room and is easily adaptable to other institutions.