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

Pharmacy Services: Outpatient Operating Room (1.20)

Pharmacy Services: Outpatient Operating Room (1.20) - Policies, Administrative, UWHC, Department Specific, Surgical Services, Administrative

1.20

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

May 1992
ORIGINAL
 REVISION

November 2015
PAGE 1
OF 2
POLICY #

1.20
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
PHARMACY SERVICES: OUTPATIENT OPERATING ROOM



I. PURPOSE

To ensure a supply of controlled and non-controlled medications for Outpatient Surgery. To ensure pharmacy
technician and registered pharmacist coverage for Outpatient Surgery. To ensure medications are properly
documented and returned to Outpatient Pharmacy at the end of the day.

II. POLICY

A. F6/206 will be staffed by a pharmacy technician from 0630-1715 Monday through Friday. The phone
number is 262-2570. In addition, the technician carries a cell phone and will pass the phone to the
Main OR pharmacy technician after hours.
B. An OR pharmacist is available from 0600-1600 Monday through Friday and can be reached bypager
at 7284. If Pharmacy staff is out of the F6/206 pharmaceutical room making deliveries to a specific
OR suite, non-controlled medications can be acquired by OR staff (nurses, anesthesia providers, and
selected personnel) by badging into the F6/206 Pharmacy or using the automated dispensing cabinet
in Ambulatory Surgery or OSC PACU. In addition, both the OSC pharmacy technician and/or the
OR pharmacist are available by phone/pager as noted above.
Tech phone: OR RPH: After hours:
OSC Pharmacy hours:
0630-1730
2-2570
Cell: 444-0054
Pager (preferred
method)
7284
Central RPH:
1600-2100: pager
7284

C. Medication needs outside of the above hours are arranged by paging the Central Pharmacist at 7284.

III. PROCEDURE

A. The anesthesia provider will pick up the anesthesia standard medication drawer (non-controlled
medications) and the single patient controlled substance pack from the pharmacy technician stationed
near the PACU, room F6/206 for each surgical case.
B. Document all medications used from the tray within the EMR.
C. Anesthesia workroom staff will return the used standard medication tray to F6/206. The anesthesia
provider will return the single patient controlled substances to F6/206 after each case. Unopened
controlled substances are returned to the pharmacy and placed in the separate “Returns” medication
secure drop in F6/206) and drawn up but not administered controlled substances (“to be wasted”
medications) are placed in a separate bag and returned in the pharmacy in the drop box labeled
“Waste”.
D. Record the amount of each patient’s controlled medications used and “to be wasted”. The narcotic
packs come with a controlled drug ledger sheet.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

May 1992
ORIGINAL
 REVISION

November 2015
PAGE 2
OF 2
POLICY #

1.20
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
PHARMACY SERVICES: OUTPATIENT OPERATING ROOM



1. Keypoint - Cross out any mistakes with a single line and initial next to the cross-out.

2. Keypoint - If extra narcotics have been issued, record and initial the added quantity.
3. Keypoint – Ensure that patient name and MRN are filled out correctly upon returning
medications to the pharmacy.
E. Complete, total, and sign the return sheet to indicate that the medications have been returned.
F. Obtain any other medications (non-narcotic) needed throughout the day from F6/206.
1. Keypoint - Each item used must be documented on the patient’s EMR.

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