/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/surgical-services/,/policies/administrative/uwhc/department-specific/surgical-services/administrative/,

/policies/administrative/uwhc/department-specific/surgical-services/administrative/119.policy

201511307

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,Surgical Services,Administrative

Pharmacy Coverage in the Main OR (1.19)

Pharmacy Coverage in the Main OR (1.19) - Policies, Administrative, UWHC, Department Specific, Surgical Services, Administrative

1.19

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 1990
ORIGINAL
 REVISION

November 2015
PAGE 1
OF 2
POLICY #

1.19
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE

PHARMACY COVERAGE IN THE MAIN OR


I. PURPOSE

This policy pertains to medications for specific patients, not to supply stock in the OR Pharmaceutical Room (E7/391),
OR rooms, etc.

II. POLICY

A. There will be identifiable Pharmacy coverage for controlled substances and pharmaceuticals 24 hours a day,
as noted by times and phone numbers.
B. For pharmaceuticals other than those available through the pharmacy technician, OR charge nurse, or
Anesthesia Workroom, a pharmacist will be contacted as per the schedule provided below.
C. A separate controlled substance pack for each patient will be checked out as per OR Policy #1.03, "OR
Controlled Substances - PM, NOC, Weekend, Holidays, Inpatient OR" and Policy #1.04, "OR Controlled
Substances - Weekdays, Inpatient OR". Medications will be picked up in the OR Pharmaceutical Room and
documented accordingly within the EMR.
D. During normal daytime operating hours (0630-2230 M-F, 0630-1430) for the weekends and holidays. . During
off hours, the medications may be sent via a central pharmacy technician or pneumatic tube (non-controlled,
nonhazardous), and picked up by the nurse accordingly.
Tech Phone: OR RPH: After hours:
Main OR Pharmacy
hours: 0630-2230
3-7296
Cell: 516-3243
Pager (preferred method)
7284
516-2463
Central RPH:
1600 – 2100: pager 7284
2100 – 0600:3-0666
Weekend: 3-0666

E. After each patient case, standard medication trays will be picked up from the OR suite and returned to E7/391
by the anesthesia material specialist or the anesthesia assistant. Unopened controlled substances in the
individual case packs will be returned by the Anesthesia provider into the secure drop box labeled “Returns”.
Controlled substances drawn up but not administered (“to be wasted”) are placed in a separate bag by the
Anesthesia Provider and return in a separate drop box labeled “Waste”.

III. OR/PACU
A. Monday through Friday
1. 0630-2230 call Pharmacy Technician, 263-7296 (carries cell phone when not in room)
2. OR Pharmacist, page 7284 0600-1600 Monday-Friday. From 1600-2100 hours Monday-Friday page the
Central Pharmacist at 7284 or call 3-0666.
a. 2000-0600, call Central Pharmacist, 3-0666 c. Sterile Products Area RPh, 263-1270 (1500-0700)
B. Saturday and Sunday, Holidays
1. 0630 - 1430 Pharmacy Technician, 263-7296 (carries cell phone)
2. Central Pharmacist, 3-0666





UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

AUGUST 1990
ORIGINAL
 REVISION

November 2015
PAGE 1
OF 2
POLICY #

1.19
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE

PHARMACY COVERAGE IN THE MAIN OR


REVIEWED BY

Megan Donovan, Senior Clinical Pharmacist 11/2015
Surgical Services Policy and Procedure Committee 11/2015

SIGNED BY

Jeff Fenne, MSN, RN
Director, Surgical Services Department