/policies/,/policies/clinical/,/policies/clinical/uwhc-clinical/,/policies/clinical/uwhc-clinical/department-specific/,/policies/clinical/uwhc-clinical/department-specific/pharmacy/,/policies/clinical/uwhc-clinical/department-specific/pharmacy/acudose/,

/policies/clinical/uwhc-clinical/department-specific/pharmacy/acudose/145.policy

201410290

page

100

UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Acudose

Acudose Return Bin Audit (14.5)

Acudose Return Bin Audit (14.5) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Acudose

14.5






Effective Date:
September 2003


⌧Pharmacy Policy Manual
Chapter: AcuDose
Operations Procedure Manual
Chapter:

Policy #: 14.5
 Original
⌧Revision 9/10
Page 1
of 2
Title: AcuDose Return Bin Audit


I. PURPOSE: To identify the procedures used in auditing medications returned to the AcuDose
cabinet return bin.

II. POLICY: The return bins will be audited routinely to verify that contents that are accounted
for as returned are physically present. If missing items are discovered in the return bin, a
discrepancy report will be written.

III. FORMS: Controlled Substance Discrepancy Form

IV. PROCEDURE
A. The AcuDose technician will run the return bin activities events report.
B. The AcuDose technician will use this report to audit and document the contents of the
return bin for each cabinet daily (even if nothing is listed on the report as being in the
return bin).
1. The AcuDose technician will document this audit by recording the quantities
of items found in the return bin, the time and date the audit was completed, as
well as legibly recording their initials.
2. For items not listed on the report but found in the cabinet the AcuDose
technician will record the name of the drug and quantity present.
3. All reports will be completed (even if nothing is listed on the report as being
in the return bin) and returned to the Narcotic Control PHA.
4. The AcuDose technician will determine the disposition of all medications
found in the return bin as follows:
a. “Discrepancy Report” for items that need to be destroyed or wasted.
b. “Return to MedCarousel” for intact medications that can be re-used.
c. “Return to NarcStation” for intact medications that can be re-used.
C. The AcuDose technician will return returned items to active inventory if in acceptable
condition for patient use.
1. If an item is not acceptable for return to the cabinet, a controlled substance
discrepancy form will be completed and the dose attached. The report and
dosage must then be returned to the Narcotic Control PHA to coordinate the
waste of the product.
2. If the item should have been wasted by the nurse who returned the item to the
return bin, the AcuDose technician will note this on the discrepancy report.
a. The yellow copy of the report will be left with the clinical nurse
manager who will follow up with the employee.






Effective Date:
September 2003


⌧Pharmacy Policy Manual
Chapter: AcuDose
Operations Procedure Manual
Chapter:

Policy #: 14.5
 Original
⌧Revision 9/10
Page 2
of 2
Title: AcuDose Return Bin Audit


b. The AcuDose technician will note on the discrepancy report the
name and phone number of the nurse manager who was provided the
yellow copy of the discrepancy report.
D. If during the audit an item is found to be missing from the report, then the AcuDose
technician will run a station events report from the AcuDose cabinet and determine
the nurse who returned the item to the return bin.
1. The AcuDose technician will then prepare a discrepancy report with the
following information
a. Type of discrepancy (missing).
b. Name of controlled substance.
c. Dose, quantity, and dosage form.
d. Name of RN who returned the medication to the return bin (from
station events report).
2. The AcuDose technician will note on report that the yellow copy of report was
given to the nurse manager by attaching a label to both copies of the
discrepancy form with the following elements completed.
3. The yellow copy is left for the nurse manager and the white copy is given to
the narcotic vault PHA with a copy of the appropriate page of the return bin
activities report and the station event’s report.
a. The AcuDose technician will highlight the appropriate events related
to the discrepancy.
4. The nurse manager will contact the Narcotic Control PHA (3-1275) with a
resolution if one can be determined. If no resolution is provided after 72
hours, then the narcotic control PHA will forward the discrepancy report to
the Pharmacy Manager for review and follow up with the nurse manager.

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



Approved By: ____________________________



Date: ____________