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AcuDose-Rx (14.4)

AcuDose-Rx (14.4) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Acudose

14.4





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

Page 1
of 10

Title: AcuDose-Rx


I. PURPOSE: To describe the capabilities and procedures associated with controlled access
cabinets (CACs).

II. POLICY: The Departments of Pharmacy, Nursing, and Respiratory Therapy shall use AcuDose-
Rx®, an automated controlled access cabinet (CAC), for the storage, dispensing, and tracking of
controlled substances, approved floorstock, and as needed medications (PRNs) in patient care
areas. AcuDose-Rx® uses touch screens to activate a variety of cabinet drawers and pocket types
for the dispensing, returning, and restocking of medications, in addition to providing
functionality for resolving discrepancies and completing administrative tasks such as running
reports. The following procedures will be used with the AcuDose-Rx® CACs:

III. FORMS: University of Wisconsin Hospital and Clinics AcuDose-Rx Override List

IV. PROCEDURE:
A. ACCESS/SECURITY
1. AUTHORIZED ACCESS - Access will be strictly maintained to ensure that only
authorized personnel can access, distribute, and document medications obtained
from the cabinet, and to ensure confidentiality of patient data.
2. Access to AcuDose-Rx will only be granted to those areas where the employee
commonly works. All requests must contain the employees first name, middle
initial, last name, User ID, employee ID, discipline and the security level of the
employee.
a. All new Nurses should have their initial Acudose access requested by
Nursing Education and Development.
b. All new Pharmacy staff should have initial AcuDose access requested
by the Pharmacy Office staff.
c. All new Respiratory Therapy staff should have their initial AcuDose
access requested by the RT Manager.
d. Changes in access must be made by the employees manager including
changes in work area or role.
3. AcuDose-Rx access requests must be treated with extreme confidentiality.
4. Different levels of access (security levels) to AcuDose-Rx are assigned to
individuals based on the functionality required by the individual:





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

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Title: AcuDose-Rx













5. Access to the Acudose will be provided via the combination of a unique User ID
(same as Healthlink login) and a unique password access code. User IDs, security
levels and cabinet access assignments will be entered into the AcuDose-Rx
support PC by Pharmacy personnel. The first time a user logs on to AcuDose-Rx,
their initial password is “PASS1”. For security purposes, upon first log on, all
users must change their password to something only known to them. Passwords
are private access codes and should not be shared with others. After passwords
are selected, each employee is responsible for maintaining the confidentiality of
his or her password. Writing down and/or posting of user IDs/passwords is
prohibited. When completing a transaction, individuals must sign-off to prevent
unauthorized access. Any breach of password confidentiality is the responsibility
of the password owner. Users are responsible for all access made with their User
ID/password; inappropriate access may result in discipline up to and including
discharge. If it is suspected that any employee’s password is no longer
confidential, it is the responsibility of the employee to immediately change their
password to prevent any security breaches. Employees may use the on-screen
menu to change their password at any time.
6. If an employee forgets their password, a request to reset their password should be
completed by the employee’s manager.
7. Temporary User Access
a. The UWHC help desk will receive all requests for temporary user
access from the user by phone and will be soley responsible for
setting up temporary user access.
b. Temporary user access will be provided upon request to provide a
user already set up in Acudose-Rx with access to work areas not
currently accessible.
c. The UWHC Help Desk will ask the employee for the last four digits
of his or her social security number to verify the employee’s identity.
POSITION SECURITY LEVEL
Travel and Agency Nurse Nurse
Staff, Float, Cluster, and Advanced
Practice RNs, LPNs, Clinical Instructors
Temporary Nurses/Students
Nurse
CNMs, Care Team Leaders Nurse Supervisor
Pharmacists Pharmacist
Pharmacy technicians Technician/ Intern
Pharmacy Management Administrator
Respiratory Therapists Respiratory Therapy





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

Page 3
of 10

Title: AcuDose-Rx

d. The UWHC Help Desk will set up the temporary user access and
email the user the password and copy designated nursing management
and Brad Ludwig who will verify appropriateness of request and
identify need for request for permanent change in access.
e. Employees must be assigned temporary user access and password
only for the shift and unit requested. Temporary access will only be
provided for 14 hours to cover the employee’s shift.
f. Permanent changes to access for an individual employee must be
handled on a case by case basis upon the direction the employees
manager.
8. Resetting of Passwords
a. The UWHC help desk will receive all requests to reset passwords.
b. The UWHC Help Desk will ask the employee for the last four digits
of his or her social security number to verify the employee’s identity.
c. The UWHC help desk will reset the employees password and email
the user the password and copy designated nursing management and
Brad Ludwig who will verify appropriateness of request and identify
need for request for permanent change in access.
9. Employees such as Travel Nurses and Contracted Employees shall be given access
to AcuDose-Rx for a limited duration. The Clinical Nurse Specialist, Nursing
Informatics, or CNM will notify the Pharmacy when these employees terminate so
their user privileges may be revoked.
10. Nursing Students may have access after their Clinical Instructor has signed onto
AcuDose-Rx. The instructor may not share their sign on/password with the
student. Alternatively, students may be granted temporary passwords at the
discretion of the CNM or Clinical Instructor.
11. Narcotic access may be limited for a user as requested.
12. Nursing Position Management will notify the Pharmacy routinely when a Nursing
employee terminates. Upon receipt, Pharmacy will revoke user privileges.
Pharmacy and RT managers will also notify Pharmacy when their employees
terminate.

B. CABINET INVENTORY
1. All medications routinely stocked in the cabinet must be on the UWHC formulary,
and comply with current UWHC guidelines for medication use.
2. Modifications to existing “floorstock” contents of the Acudose will be completed
through the following procedure:
a. The request will be communicated via the University of Wisconsin
Medication Area/Floor Stock Request” form.





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
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Revision 10/15

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Title: AcuDose-Rx

b. The request will be advanced to the Drug Product Supply and
Selection Committee (DPSS) for review.
c. If approved, the medication will be added to the unit-based cabinet’s
inventory as soon as possible. If, however, the medication is rejected
for placement in the cabinets, then the appropriate Pharmacy
Managers will notify the original requester, and reevaluate the
request.
d. All Acudose cabinets contain standard stock medications. Any new
medications to be considered for stock with the exception of
Controlled Substances II and III must be requested and reviewed by
the DPSS Committee.
3. When an order is received for a CII-III controlled substance which is not routinely
stored in a units cabinet, that medication will be assigned to a specific locked
lidded drawer within the cabinet by an Acudose Technician (as requested by the
decentral pharmacist, PhA, or triage label) in a timeframe which meets patient
care needs.
a. When a patient is on a Narcotic Drip these may be delivered or tubed
to the appropriate area. If tubed, the drug must be tubed using the
Secure tubing functionality of the tube system. The medications will
be stocked in AcuDose by the Pharmacy Technician. The Narcotic
drips will be restocked in the Acudose cabinet under Narc Drips, the
Nurse will then dispense each per patient. When a patient on a
narcotic drip transfers to a new nursing unit, the Pharmacy Technician
from which the patient is transferring must “Expire” that patient’s
drip from the old Acudose cabinet and “Restock” it in the cabinet on
the patient’s new unit.
b. A prescriber’s order is needed to use a patient’s own supply of
medications. Patient’s own supply of Controlled Substances will be
stored and maintained in AcuDose.
1. The patient’s bottle should be forwarded to the unit pharmacist.
The pharmacist will:
 Verify the medication.
 Count the number of tablets/ml’s in the container
 Attach the Stored Medication Record to the container holding
the medication(s).
 The Pharmacy technician will restock the correct quantity
(tablets or ml’s) into the locked Acudose pocket called “Pt’s
Own Controlled Substances”.
 Nurses dispense the correct number of tablets or ml’s in the
Acudose each time the medication is dispensed.





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
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Revision 10/15

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Title: AcuDose-Rx

 Upon patient discharge:
 The RPH and PHA count the quantity remaining in the bottle.
 The PHA will expire the quantity remaining in the bottle
from the Acudose cabinet.
 The Nurse or Pharmacist then returns the bottle to the patient.
c. Patient’s own controlled substances may be stored within an Acudose
for the purposes of securely storing a medication without a
prescriber’s order.
1. The patient’s bottle should be forwarded to the unit pharmacist.
The pharmacist will:
 Verify the medication.
 Count the number of tablets/ml’s in the container.
 Place the container(s) in secure bag with the Stored
Medication Record.
 Refer to Policy 3.2 Stored Medications for additional
instructions.
 The Pharmacy technician will restock the correct quantity
(number of containers) into the locked Acudose pocket called
“Pt’s Own Stored Controlled Substances”.
2. Upon patient discharge:
 The RPH and PHA count the quantity remaining in the bottle.
 The PHA will expire the quantity remaining from the
Acudose cabinet.
 The Nurse or Pharmacist then returns the bottle to the patient.
4. All Epidural and PCA keys will be stocked and maintained within AcuDose.
a. Epidural and PCA keys will be secured in lock-lidded pockets and be
treated as a controlled substance. Counts will be required upon
dispensing and be included in the shift counts.
b. Epidural and PCA keys will be returned to the AcuDose pocket when
not in use.
c. Epidural and PCA keys to control the locked infusion pumps will be
distributed to each patient care area as appropriate.
d. The epidural and PCA key distribution process is owned and operated
by the Pharmacy Department via the Assistant Director of Pharmacy.
e. Requests for authorization of initial or replacement issuance of epidural
and PCA keys for locked epidural, intrathecal, and patient controlled
analgesia (PCA) pumps shall be directed to the Assistant Director of
Pharmacy Operations/Technology for his/her approval.
f. For a replacement request in which a count discrepancy has been
created all efforts must be made to resolve the discrepancy. If the





Effective Date:
December 2002
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Chapter: AcuDose
 Operations Procedure Manual
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Revision 10/15

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discrepancy cannot be resolved, and the key not located, a ‘Controlled
Substance Discrepancy” form must be completed prior to issuance of a
replacement key.
g. Upon approval from the Assistant Director of Pharmacy initial or
replacement issuance of an epidural and PCA key will be stocked or
restocked by the AcuDose Technician.
h. Backup epidural and PCA keys shall be kept in the Central Pharmacy
narcotic vault with a separately designated epidural/PCA key issuance
log to be maintained by the narcotic vault technicians.
5. Refer to section 7.0 of this policy for inpatient/clinic/procedure area nursing
responsibilities regarding epidural and PCA key dispensing and returning to
AcuDose cabinets, shift counts, missing key investigations, and narcotic
discrepancy procedures.
6. When an order is received for any PRN medication (other than a C2-3 controlled
substance) which is not routinely stored in a unit’s cabinet, a supply of the doses
will be filled and sent to the patient care area. The request will indicate the
medication and quantity to be filled. When the doses arrive on the floor, the
Pharmacy technician will put the medications into the patients scheduled
medication drawer.

C. MEDICATION ADMINISTRATION
1. For consistent use in accessing medications and maintaining related records, the
following procedures will be followed when obtaining medications for patients and
performing all related activities:
a. All medications administered (or held) must be documented on the
Medication Administration Record (MAR), as this is the permanent
medical record. Removal/Returning medications to the Acudose-Rx will
charge/credit the patient, but this DOES NOT constitute documentation.
b. If a multi-dose item is removed from AcuDose-Rx, label the item with
the patient’s name and date and place it in the patient’s scheduled
medication drawer for future use. Access another multi-dose item from
AcuDose-Rx only when the patient runs out of this initial supply, as the
patient will be charged for each item removed from AcuDose-Rx (not
from the patient’s scheduled medication drawer).

D. PROFILE DISPENSING
1. Medication orders must first be entered into the Pharmacy order entry system to be
accessed from AcuDose-Rx unless the medication is selected using override (See
OVERRIDE FUNCTION below). When a specific patient is selected, that
patient’s medication profile will be displayed.





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

Page 7
of 10

Title: AcuDose-Rx

a. Medications on the patient’s profile displayed with a “white background”
indicate the medications stocked and available in AcuDose-Rx for that
particular patient.
b. Medications on the patient’s profile displayed with a “gray background”
indicate those medications that are not available via AcuDose-Rx. Please
see pharmacy regarding dispensing of these medications if questions.
c. Please note that the medications listed in AcuDose-Rx do not represent
the patient’s medication administration record (MAR). The MAR (or
practitioner’s order) must be consulted prior to accessing the medication.
2. If the medication is not listed in the AcuDose-Rx profile, the following may apply:
a. The order has not been entered into Heathlink or has not yet been verified
by a pharmacist.
b. The medication is not in the AcuDose-Rx formulary or inventory.

E. OVERRIDE FUNCTION - FOR PROFILE DISPENSING
1. Override criteria are based on the risk of poor patient outcomes from not receiving
a medication before a pharmacist reviews the order. This risk must outweigh the
risk of a nurse administering an incorrect or inappropriate medication. Nurses may
not dispense a medication via override simply because that medication is on the
override list. Rather, specific criteria for when nurses may dispense a drug via
override before a pharmacist reviews the medication order against the patient's
medication profile (and other relevant patient information) are as follows:
a. For an emergency or STAT situation when time does not permit such a
review by a pharmacist, and the resulting delay to do so would result in
clinical harm to the patient (Code Blue, etc.)
b. For a 1st dose in an urgent situation where the clinical need of the patient
demands immediate administration (morphine for acute pain, diazepam
for DTs, or Nitroglycerin for angina). In such cases, the pharmacist still
reviews the order in a timely manner following administration.
c. When a licensed practitioner/prescriber controls ordering, dispensing and
administration or directly oversees the administration of the drug (i.e.
Emergency Room).
d. When administering a medication via the override function the nurse is
responsible for determining appropriateness based on the above criteria.
The nurse must verify selection of the correct patient; review the patient’s
profile, allergies, and all other pertinent clinical criteria before
administering the medication.
e. If the above information has been verified and the override medication is
needed, proceed by dispensing the medication via the “OVERRIDE”
button.





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

Page 8
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Title: AcuDose-Rx

f. If the override drug is not available the nurse should expedite the order
entry procedure to facilitate availability of the drug. This includes
sending all NOW / STATs to the pharmacy for rapid order entry.
g. An approved medication Override List will be maintained. Medications
will be available via the Override function only if they have been
approved for Override Status following review from the DPSS
Committee.
2. Pharmacy will monitor/analyze medications dispensed via an “override” and
determine the appropriateness. Pharmacy will forward concerns/issues to the
appropriate nurse manager as needed.

F. ENTERING PATIENT INFORMATION
1. Patient information for all nursing units is entered into AcuDose-Rx by an
interface with the Hospitals Admission/Discharge/Transfer (ADT) patient
registration system. The patient’s name should appear on the AcuDose-Rx census
list.
2. If patients are not listed on the AcuDose-Rx census list at the time a medication is
needed, the nurse shall enter the patient into AcuDose-Rx manually into a
phantom bed called WILD 01.

G. WASTED MEDICATIONS – CONTROLLED SUBSTANCES
1. All controlled substances which are removed from their original package and/or
not suitable for use with another patient must be wasted and documented as
wasted by two “licensed” nurses. Such doses should not be returned to the
Acudose cabinet or to Pharmacy.
2. The dose actually administered to the patient must be documented on the MAR,
but waste should only be documented in Acudose.
3. All medication waste should be wasted in the appropriate waste stream Container,
not in the Pharmacy Return Bin.

H. RETURNING MEDICATIONS
1. Medications removed from AcuDose-Rx which are intact and have not been
administered to the patient must be returned to AcuDose-Rx using the
“RETURN” procedure. This ensures that the patient receives credit for drugs not
administered to them. If the medication is a controlled substance, two licensed
nurses must witness the return and document this in the cabinet.
2. Due to the configuration of the cabinet, medications returned to the cabinet are
placed in the RETURN BIN, if applicable, located in the bottom drawer of the
cabinet. The central pharmacy will manage all returns and process them
according to their subsequent usability.





Effective Date:
December 2002
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Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
Original
Revision 10/15

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Title: AcuDose-Rx

3. No uncapped or manipulated needles should be placed in the Return Bin, instead
place them in the Hazardous Substance Waste and waste them per procedures
described in 5.0 above.
4. Defective dosage forms should be returned to pharmacy via the Return Bin in a
zip-locked bag with a note attached describing the problem.

I. DISCREPANCIES – CONTROLLED SUBSTANCES AND EPIDURAL/PCA KEYS
1. The presence of a controlled substance or epidural/PCA key discrepancy is clearly
displayed on every cabinet in the bottom right corner. When there is a controlled
substance or epidural/PCA key discrepancy the phrase “Narc Discrepancy” and
the # of discrepancies will appear in red. All discrepancies continue to appear on
the screen until the discrepancy is resolved in the cabinet.
2. Each time a nurse dispenses a controlled substance or epidural/PCA key, she/he is
expected to count and document the remaining quantity in the pocket. If the count
entered does not agree with that calculated by the cabinet a “discrepancy warning”
message will appear. If a discrepancy warning is generated, then the nurse must
correct the inventory count in AcuDose-Rx immediately. This correction
automatically generates a discrepancy in the AcuDose.
3. Before the conclusion of each shift the CNM or their designee is responsible for
resolving all discrepancies on the cabinet(s) on their unit, with an appropriate
resolution via investigation or the completion of a narcotic discrepancy form, and
document in AcuDose-Rx or previously stated narcotic discrepancy form.

J. RESTOCKING MEDICATIONS and EMPTYING RETURN BIN
1. All Acudose cabinets contain standard stock medications. New medications to be
considered for stock with the exception of Controlled Substances II and III must be
requested and reviewed by the Drug Products Supply and Selection Committee
(DPSS). Any new narcotic medications requested can be stocked into the cabinet in
a locked lidded pocket, if there is no room available a medication that is not on the
“Do not unassign” list may be removed.
2. The Acudose technician will restock the Acudose cabinet daily utilizing the
barcode restocking function. All medications are checked before being restocked.
The following guidelines should be followed when restocking medications:
a. All controlled substances II-V are stocked in either a lock-lidded or high
capacity lock-lidded pocket. Medications are in appropriate sized
pockets.
b. Max/Par levels are set with an adequate supply, no overstocking. Look
alike medications are not stocked together in the same matrix drawer.
c. All High Alert medication storage pockets are labeled with appropriate
label





Effective Date:
December 2002
Pharmacy Policy Manual
Chapter: AcuDose
 Operations Procedure Manual
Chapter

Policy #: 14.4
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Revision 10/15

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Title: AcuDose-Rx

d. Pharmacy prepared injections should not be stored in the same drawer. If
items must be stocked in the same drawer, due to space constraints they
should not be stored in adjacent matrix pockets if applicable.
3. The Narcotic technician will verify that controlled substance medications, which
were removed from the narcotic vault, were loaded into the AcuDose-Rx cabinet
via the closed loop transaction process in NarcStation.
4. Stock and inventory level changes for medication stored in AcuDose-Rx will be
based on usage and patient convenience, and will be periodically adjusted to meet
customer needs.
5. The Acudose technicians will empty the Acudose-Rx return bins routinely. The
Return Bin report will be generated by the Acudose technician who will then
indicate on the report if the medication was found. If the medication is not found
a discrepancy report is written and given to the CNM for follow up. All reports
are returned to the NarcStation area daily.

K. INVENTORY COUNT/EXPIRATION DATES
1. Expiration date audits will be periodically completed and documented by pharmacy
personnel per Pharmacy Department policy. Inventories are also audited for
appropriateness at this time
2. All personnel inventory (via a blind count) controlled substances during each
pocket access.

L. TROUBLE SHOOTING AND DOWNTIME
1. Contact Aseynt Automated Healthcare Help Desk (1-800-700-8737) for any
problems with the cabinet. If Aseynt determines that an equipment failure has
occurred, a local field service technician will be dispatched.
2. Refer to AcuDose Downtime policy 14.1 in the event down time procedures are to
be implemented.

V. COORDINATION:
A. AUTHORED BY: Brad Ludwig
B. REVIEWED BY: Steve Rough, MS, RPh
C. COMMITTEE APPROVAL BY: PPIRC



Technician Training Manual
Pharmacist Training Manual



Approved By: ____________________________
Director of Pharmacy Services

Date: ____________