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Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Central Unit Dose (CUD)

Medication Delivery Via Pneumatic Tube System (4.1)

Medication Delivery Via Pneumatic Tube System (4.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Central Unit Dose (CUD)

4.1





Effective Date:

September 2003
⌧ Pharmacy Policy Manual
Chapter:
Operations Procedure Manual
Chapter:

Policy or Procedure:
4.1
 Original
⌧ Revision 8/11
Page 1
Of 5
Title: Medication delivery via Pneumatic
Tube System


I. PURPOSE: To establish guidelines to define which medications cannot be delivered
through the pneumatic tube system (PTS) from Central Pharmacy to remote sites and
outline procedures for secure transactions for controlled substance.

II. POLICY: Medications may be distributed through the PTS unless specifically
restricted. Items prohibited from the PTS because of damage being done to the
product, the pneumatic tube system, or because of potential harm to the user of the
pneumatic tube system are defined in this policy

III. ATTACHMENTS: Appendix A: Medication that cannot be delivered via PTS

IV. FORMS: Remote Site Narcotic Log

V. PROCEDURE
A. Types of products that cannot be sent through the pneumatic tube system.
1. Product exceeds pneumatic tube weight and/or size limit.
2. Potential for alteration of the active ingredients or vehicle exists.
a. Protein denaturation
b. Cracking of emulsions
3. Hazardous drugs (see UConnect for complete listing).
a. Labeled with "Hazardous Drug " sticker
4. Items that may break during pneumatic tube delivery
a. Glass bottles greater than or equal to 250ml.
5. Living therapeutic modalities.
6. Controlled substances.
a. For circumstances where controlled substances can be tubed, see section
d "Tubing Schedule II Controlled Substance Drips via the Pneumatic Tube
System."
7. Substantial monetary or labor loss if the medication is "lost" during transport.
8. Explosive or flammable substance.


B. If a medication is ordered that cannot be sent through the PTS but is scheduled
due prior to the time a delivery would be made to the area, the central pharmacist
or designee will contact the decentral pharmacist covering that unit to inform
them that tube delivery is not possible. The decentral pharmacist will then decide
how the medication will reach the floor.
1. The pharmacist can have the medication put on the next delivery run if the
medication is not needed urgently.
2. The decentral Pharmacy Technician covering that unit can pick up the
medication from Central Pharmacy and deliver it to the patient care area.






Effective Date:

September 2003
⌧ Pharmacy Policy Manual
Chapter:
Operations Procedure Manual
Chapter:

Policy or Procedure:
4.1
 Original
⌧ Revision 8/11
Page 2
Of 5
Title: Medication delivery via Pneumatic
Tube System

C. Tubing of Scheduled II Narcotic Drips
1. Only patient specific scheduled II controlled substance drips may be sent via
PTS.

2. When the item is ready to be delivered by the PTS a central technician will
initiate the delivery process using the following procedure:
a. The central technician will contact the remote site to notify the receiving
technician/RPh that the item is ready to be sent via the PTS, and provide
the 4 digit code that he/she will enter as the security code. This number
will always be the last digits of the sender’s UWHC ID badge number.
The central technician will also request the UWHC badge number of the
technician/RPh receiving the controlled substance.
b. The central technician will verify the technician/RPh’s name and UWHC ID
badge number against the list maintained in the SPA.
c. The central technician will sign out the controlled substance on the SPA
Narcotic Use Record by recording his/her name and UWHC ID badge
number in the “Tubed by” column. Record the last name and badge
number of the person receiving the narcotic in the “Rec’d by” column. (ed.
Musa/6543; Kreling/1234).
d. The central technician will then send the item h
01 Press MENU button and select USER SPECIAL FUNCTIONS by
pressing ENTER;
02 Toggle down to SECURE TRANSACTION and press ENTER;
03 On “ENTER SECURITY CODE” screen enter the last 4 digits of (the
senders) UWHC ID badge number, and press ENTER;
04 Enter destination and press SEND.

3. Upon arrival of the secured tub to the remote site, the recipient will use the
same 4 digit code entered by the sender of the tube to release the tube via
the following procedure:
a. When the tube arrives, the station will alarm and a prompt to enter the
security code will appear on the screen;
b. The receiving person will then enter the security code number given to
them by the central technician which will release the tube.

4. If the area involved is an Acudose unit, the schedule II controlled substance
drip MUST be logged into the Acudose system for tracking purposes
a. The individual who receives the controlled substance drip must be the
same person who logs the item into Acudose.
b. If another person logs the drip into Acudose, a phone call by the receiving
person to the narcotic control technician must be made (3-1275) to inform
them that someone else logged the drip into Acudose. A message may
be left on voice mail if the narcotic control technician is not available.





Effective Date:

September 2003
⌧ Pharmacy Policy Manual
Chapter:
Operations Procedure Manual
Chapter:

Policy or Procedure:
4.1
 Original
⌧ Revision 8/11
Page 3
Of 5
Title: Medication delivery via Pneumatic
Tube System


5. If the area involved is not an Acudose unit, a log will be maintained in the
remote site to document all narcotics/CII drug products received via the PTS
and will include the following information.
a. Name of the medication
b. Patient’s name
c. Time removed from the PTS
d. Initial of the person receiving the medication.

6. In the event a tube does NOT arrive at the remote site, the recipient will notify
the SPA Pharmacist. The SPA pharmacist will then contact Plant
Engineering (3-5205) to initiate a search for the missing tube.

7. In the event a Narcotic drip arrives at the remote site and is NOT sent in the
secure transaction mode, the recipient will immediately notify the SPA
pharmacist will then contact the Central staff involved and complete a
Narcotic Discrepancy Report.



Approved By: ____________________________
Director of Pharmacy Services

Date: ________________




Appendix A

Medications that Cannot be Delivered via Pneumatic Tube System

Drug Rationale
Abciximab Potential for drug product degradation, monetary loss
Albumin Potential for drug product degradation, monetary loss
Alemtuzamab Potential for drug product degradation, monetary loss
Alteplase Potential for drug product degradation, monetary loss
Antihemophilic factors (III,
VIIa, VIII, IX)
Potential for drug product degradation, monetary loss
Antithymocyte Globulin Potential for drug product degradation, monetary loss
Basiliximab Potential for drug product degradation, monetary loss
Botulinium toxin-A/-B Potential for drug product degradation, monetary loss
Hazardous Drugs See UConnect for complete listing of agents. 
Daclizumab Potential for drug product degradation, monetary loss
Darbepoetin Alfa Potential for drug product degradation, monetary loss
Dornase Alfa Potential for drug product degradation, monetary loss
Drotrecogin Alfa Potential for drug product degradation, monetary loss
Enanercept Potential for drug product degradation, monetary loss
Epoetin alfa Potential for drug product degradation, monetary loss
Fat/lipid emulsions Glass bottle, potential for drug product degradation
Filgrastim Potential for drug product degradation, monetary loss
Glatiramer (Copaxone) Potential for drug product degradation, monetary loss
Human growth factor Potential for drug product degradation, monetary loss
Immune globulin products
(CMV, Panglobulin, Polygam)
Potential for drug product degradation, monetary loss
Infliximab Potential for drug product degradation, monetary loss
Leeches Maybe harmed by tubing process, monetary loss
Magnesium citrate Glass bottle, potential for drug product degradation
Muromonab-CD3 Potential for drug product degradation, monetary loss
Palivizumab Potential for drug product degradation, monetary loss
Pegfilgrastim Potential for drug product degradation, monetary loss
RSV Immune globulin Potential for drug product degradation, monetary loss
Reteplase Potential for drug product degradation, monetary loss
Rituximab - Potential for drug product degradation, monetary loss
Somatropin (Humatrope,
Nutropin)
Potential for drug product degradation, monetary loss
Streptokinase Potential for drug product degradation, monetary loss
Tenecteplase Potential for drug product degradation, monetary loss
Thiopental Drips Potential for drug product degradation, glass bottle
TPN/TNA
Potential for drug product degradation, monetary loss





Remote Site Narcotic Log
Date Medication Bag
Number
Patient
Name
MR# Received
By
Issued
To