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Policies,Administrative,UWHC,Department Specific,Pharmacy,Controlled Substances

Preparation of Liquid Unit Dose Product from Bulk Controlled Substances (7.19)

Preparation of Liquid Unit Dose Product from Bulk Controlled Substances (7.19) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Controlled Substances

7.19

POLICY & PROCEDURE





Effective Date:

March 2017
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter: Administration

Policy 7.19
 Original
 Revision

Page 1
of 2

Title: Preparation of liquid unit dose product
from bulk controlled substances



I. PURPOSE: This policy coordinates the preparation of inpatient oral liquid unit dose
products from bulk controlled substances at University Hospital, American Family
Children’s Hospital, The American Center, and UW Health Rehabilitation Hospital.

II. PROCEDURE
A. Narcotic vault technician:
i. Assess inventory of liquid unit dose controlled substances and determine if
additional inventory is necessary.
ii. Reorder the liquid unit dose controlled substance:
1. If this is repackaged internally, the narcotic vault technician will:
a. Complete the “Repack Stock Order Form”, if applicable,
indicating the quantity of product required.
b. Issue the liquid controlled substance bulk bottle to the non-
automated unit “Narcotic Repackaging”.
i. Should the bulk controlled substance need to be
prepared, the narcotic vault technician will:
1. Issue the appropriate amount of components
to the non-automated unit “Narcotic
Manufacturing” to prepare the UW Health
bulk controlled substance.
2. Bring controlled substance and the
controlled substance receipt to the
manufacturing technician for compounding.
c. Bring the liquid controlled substance bulk bottle and
controlled substance receipt to the repackaging technician.
iii. Stock the liquid unit dose controlled substance in the narcotic vault.
iv. Complete a return into NarcStation:
1. If a full bottle is repackaged, complete a zero return for the bulk
controlled substance and indicate how many liquid unit dose
controlled substances were prepared from the total volume of the
liquid bulk controlled substance.
2. If a partial bottle is repackaged, complete a return and indicate the
amount of liquid remaining in the bottle and how many liquid unit
dose controlled substances were prepared from the volume of the
liquid bulk controlled substance used.

POLICY & PROCEDURE





Effective Date:

March 2017
 Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter: Administration

Policy 7.19
 Original
 Revision

Page 2
of 2

Title: Preparation of liquid unit dose product
from bulk controlled substances


v. Stock the liquid unit dose controlled substance in the narcotic vault
B. Manufacturing technician:
i. Compound the bulk controlled substance per the recipe in the
compounding database and in accordance with standard compounding
procedures.
ii. Prepare unit dose products in accordance with standard non-sterile
preparation procedures.
iii. Bring the unit dose product and the controlled substance receipt back to
the narcotic vault technician to reconcile prepared product.
C. Repackaging technician
i. Prepare unit dose products in accordance with standard non-sterile
preparation procedures.
ii. Deliver the prepared unit dose product to narcotic vault.

III. FORMS
A. Repack Stock Order Form

IV. COORDINATION
A. Authored by: MegahnnVoegeli, PharmD, MS; Ryan Craynon, PharmD
B. Committee Approval: Pharmacy Inpatient Operations Committee




Approved By: _________________________________

Director of Pharmacy

Date: __________________