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Checking for Expired Medications at UWHC Ambulatory Pharmacies (2.12)

Checking for Expired Medications at UWHC Ambulatory Pharmacies (2.12) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Ambulatory

2.12

POLICY & PROCEDURE





Effective Date:

July 2002

Chapter: Ambulatory

Chapter:

Policy #: 2.12


 Revision 3/17

Page 1
of 3

Title: Checking for Expired Medications at
UWHC Ambulatory Pharmacies


I. PURPOSE: To establish guidelines for checking of expired medications in the Ambulatory
Pharmacy sites.

II. POLICY: All UWHC Ambulatory Pharmacy sites will check all medication expiration dates
at least monthly. Any medication having an expiration date within the next 30 days will be
removed from the pharmacy inventory.

III. PROCEDURES:
A. Expiration date checking may be accomplished at any time during the month. The
Ambulatory Pharmacy sites may be divided into assigned areas to complete check for
expired medications in a timely manner (See Appendix A. Drug Expiration Date Audit).
B. The Drug Expiration Date Audit list will be posted on the narcotic cabinet as a
standardized location at each site and will be used to mark the progress of the monthly
expiration checking.
C. Pharmacy technicians will be assigned to visually audit specific areas of pharmacy
inventory for expired medications. Students and volunteers may be directed to complete
the visual expiration date audit as time permits during their scheduled work shift.
a. Schedule II controlled substances:
i. Expired schedule II controlled substances will be processed according to
Pharmacy Policy 7.14 Schedule II Controlled Substance Procedure for
Ambulatory Pharmacies.
ii. Only UWHC pharmacy employees are permitted to complete expiration
audits of schedule II controlled substances. Volunteers are not permitted to
perform this task.
D. All items (both prescription and Over the Counter (OTC)) expiring within 30 days will be
removed from physical inventory. Expiring prescription medications will be deducted
from the pharmacy software system’s inventory. Expired medications must be stored in a
bag or bin marked “Expired Medications.”
a. Removal of inventory from pharmacy software
i. Only UWHC pharmacy employees are permitted to adjust inventory in
pharmacy software system. Volunteers are not permitted to perform this
task.
ii. Inventory must be adjusted in pharmacy software system prior to placing
in segregated, labeled expired medication bin for return.

POLICY & PROCEDURE





Effective Date:

July 2002

Chapter: Ambulatory

Chapter:

Policy #: 2.12


 Revision 3/17

Page 2
of 3

Title: Checking for Expired Medications at
UWHC Ambulatory Pharmacies

E. Short expiration inventory, items that will expire within 6 months, will be rotated to the
front of the stock to be used first and marked with a colored “dot” to indicate short
expiration.
F. Medications that have been “Returned to Stock” and are not in the original medication
packaging expire six months from the dispense date on the prescription container.
G. Expired medications will be picked up and processed by a contracted return company,
destroyed, or sent back to manufacturer for return and/or credit at least biannually.
H. Once monthly medication expiration audit is complete, pharmacy staff at each respective
location must document the completion of the expiration audit in the online pharmacy
audit software system.
I. Outpatient Pharmacy coordinators will review audit reports of completion or
documentation monthly and will prepare corrective actions to remedy any deficits.



Approved By: ____________________________
Director of Pharmacy Services

Date: ____________

ATTACHMENT A




DRUG EXPIRATION DATE AUDIT
UW PHARMACY__________________ Fiscal Year__________
JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE
ORALS A-F


ORALS F-Z


Look A Like,Sound A Like (LASA)
LIQUIDS


OPHTHALMICS


LOCKED NARCOTICS


TOPICALS


INHALERS


REFRIGERATOR
Document temperature
RECTAL/VAGINAL/DIABETICS


INJECTABLES


OTC’S


Compounding/Flavor Rx
Hazardous Drugs