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Policies,Administrative,UWHC,Department Specific,Pharmacy,Administration

Distribution and Use of Medication Dispensing Pins (1.41)

Distribution and Use of Medication Dispensing Pins (1.41) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.41




Effective Date:

November 2003
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy # : 1.41
Original
 Revision 12/14

Page 1
Of 2

Title: Distribution and Use of Medication
Dispensing Pins


I. PURPOSE: To outline the approved locations for medication dispensing pins
throughout the UWHC organization to ensure safe patient care.

II. POLICY: Only areas specifically authorized to use medication dispensing pins will
be allowed to maintain pins in inventory.

III. PROCEDURE:

A. Approved Use of Dispensing Pins
1. For the withdrawal of a limited number of medications from a container
where the use of a safety needle is not feasible.
2. For the withdrawal of any medications from a container where the
manipulations are done as a single episode of preparation inside of a
properly certified and maintained laminar flow hood.
B. After the preparation period, the vial and the dispensing pin shall be discarded and
not used as a multiple entry devise for the medication container.
C. Medication dispensing pins may only be used in areas approved by the Director of
Pharmacy. The following areas are approved locations for storage and use of
medication dispensing pins, but only for approved indications as outlined in
section a above.

Approved Area Location
Sterile Products Area E5/121
The operating room E7/391
The ambulatory surgery operating
Room
F6/206
Radiology D4/369
E3/377
E3/365
E3/347
E1/317
Cardiac Catheterization Lab F6/330
Nuclear Medicine E1/378
GI/Bronchoscopy D6/225
ECG G3/441
Stem Cell Lab H4/551
Pharmacy Locations other than E5/121
for use in product preparation in laminar
flow hoods.
Varies





Effective Date:

November 2003
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy # : 1.41
Original
 Revision 12/14

Page 2
Of 2

Title: Distribution and Use of Medication
Dispensing Pins


D. Resupply of Medication Dispensing Pins
1. The pharmacy will restock those areas that are approved to stock
dispensing pins daily.
2. After hours and on weekends/holidays the area must page the Acudose
technician (pager 7597) who will come to the room that is depleted and
restock. Areas may not come directly to the pharmacy to pick up these
items and they may not be tubed to requesting areas.
3. Supplies will be charged to each area as they are ordered through
Peoplesoft or OrderRx..
E. Monitoring Use of Dispensing Pins
1. Compliance with this policy will be audited by the appropriate pharmacy
technician or pharmacist through the monthly regulatory inspection (see
P&P 1.19 Regulatory Compliance Inspections).
2. Related Policies: 1.19 Regulatory Compliance Inspections

IV. Coordination:
A. AUTHORED BY: Pharmacy Manager, Business Operations
B. REVIEWED BY: PPIRC
C. COMMITTEE APPROVAL BY: PPIRC


Approved By: ____________________________
Director of Pharmacy Services

Date: ____________