/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/clinics/,

/policies/clinical/uwhc-clinical/department-specific/pharmacy/clinics/156.policy

20170383

page

100

UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Clinics

Critical Care Case Pack Systems Supplied to Med Flight and CHETA (15.6)

Critical Care Case Pack Systems Supplied to Med Flight and CHETA (15.6) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Clinics

15.6

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 1
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA


I. PURPOSE: The Department of Pharmacy will provide and oversee medications for Med
Flight and CHETA use during transport in the form of Case Packs.

II. POLICY:
A. The medications in the Case Packs must always be available, ready to use, and not
outdated.
B. The Pharmacy Department is responsible for dispensing and facilitating restocking of
Case Packs.
C. The Case Packs will be stored and maintained in a locked storage area. The integrity of
the Case Packs is assured via a numbered locking system. The Case Packs will remain
locked at all times with numbered plastic breakaway seals. The integrity of the locked
Case Pack system is checked each shift and documented on the audit form by assigned
nursing staff.

III. FORMS
A. Appendix 15.6a – Example Box, Case Pack, Kit, and Tray Accountability Log
B. Appendix 15.6b – Example Med Flight Case Pack Audit Form
C. Appendix 15.6c – Example Med Flight Administration Documentation and Charge Form
D. Appendix 15.6d – Example CHETA Case Pack Audit Form
E. Appendix 15.6e – Example CHETA Charge Form
F. Appendix 15.6f – Example CHETA Refrigerated Medications Order Form

IV. PROCEDURE
A. Locations, contents and contact information for Case Packs will be maintained in the
Stock List Database managed by Pharmacy.
1. The Stock List Database is located on the J-drive: J:\Rx\RXShare\Clinics.
a. The pharmacy department will provide and maintain medications in Case
Packs that will be located in the secure storage locations. These locations
are to be locked at all times when not in use.
b. The key to the locked area must be maintained and secured by nursing
staff. It is not permitted to have this key stored in a hidden location, but
instead it must be maintained at all times in the possession of a nursing
staff member.
c. Pharmacy also maintains a key to the room for restocking purposes. This
key is secured via “KeyWatcher” in the Central Pharmacy when not in
use.

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 2
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA

d. The technician will sign the key out at the beginning of their shift and sign
it back in at the end of their shift.

2. The Pharmacy Manager Patient Care Services / Medication Safety Officer will be
responsible for maintaining the Stock List Database when adjustments are
approved.
a. A total of 26 Case Packs will be maintained
i. 17 Med Flight Case Packs
ii. 9 CHETA Case Packs
b. Med Flight and CHETA Case Packs are sealed with numbered plastic
breakaway seals within the locked storage area.

B. Adjustments to the contents, quantities and locations of Case Packs must be approved by
the Resuscitation Review Committee.
1. Review of Case Packs will occur on a semi-annual frequency for adjustments
a. Critical Care Transport Operations Committee will submit a proposal for
adjustments
b. Drug Product Selection and Supply Committee will review proposal and
provide recommendations
c. Proposal adjustments and committee feedback will be presented to the
Resuscitation Review Committee for final approval

C. Restocking
1. Case Packs that are opened will be restocked by Pharmacy technical staff on a
daily basis.
a. If a Case Pack is open the technician will bring the open Case Pack to
Central Pharmacy for restocking daily.
b. A replacement Case Pack will be signed out from the narcotic Vault and
delivered to the locked storage area the same day.
i. The narcotic Vault technician will issue the replacement Case Pack
to the pharmacy technician
ii. The pharmacy technician will record both the lock number and the
Case Pack number on the narcotic vault issue receipt.
iii. The pharmacy technician will sign the issue receipt taking
possession of the replacement Case Pack.

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 3
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA

d. The pharmacy technician will document restocking of the Case Pack on
the audit form under the appropriate date. The technician will record the
new lock number and initial under the restocked Case Pack.
2. Restocking of CHETA Case Pack Refrigerated Medications and NaCl 3% locked
box
a. CHETA staff will be responsible for completing the “CHETA
Refrigerated Restock Form” and tubing this form to central pharmacy.
b. Central pharmacy staff will complete the order and call the CHETA nurse
phone to verify if the order should be tubed to the Emergency Department
or be placed in a bin in the stockroom refrigerator for pick up by CHETA
staff at a later time.
i. NaCl 3% locked box and proactant alpha (Curosurf® surfactant)
must be picked up in central pharmacy

D. Documenting medication administration and wastage.
1. All medications administered from a Case Pack must be documented on the
correct charge form.
a. A blank two ply charging form will be placed into each Case Pack when it
is replenished.
2. Med Flight staff must complete the “Administration and Documentation Charge
Form” to include:
a. Medication and amount ordered
b. Time ordered/administered
c. Amount administered (Note: time ordered equals time administered)
d. For controlled substances, a licensed professional must document the
amount wasted. A second licensed professional must witness and sign the
form.
e. The nurse and physician administering the medications must sign and date
the bottom of each charge form.
f. The original copy of the form will be placed in the patient’s chart.
g. The duplicate (yellow) copy of the form will be returned with the Case
Pack for billing and restocking purposes.

3. CHETA staff must complete the “Charge Form” to include:
a. Medication and amount ordered
b. The original copy of the form

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 4
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA

c. The duplicate (yellow) copy of the form will be returned with the Case
Pack for billing and restocking purposes.
4. Med Flight staff will return opened Case Pack to the designated locked storage
area and sign in on the audit form. Case Packs removed from the locked area
must be signed-out on the audit form.

E. Central Pharmacy replenishment process of Med Flight and CHETA Case Packs
1. The pharmacy technician responsible for replenishing Case Packs will bring the
opened packs to the repackaging area in the central pharmacy.
2. All Case Packs must be replenished the same day and returned to the narcotic
vault for proper security of controlled substances.
3. The repackaging technician will take the completed charge form from the Case
Pack and complete two refill requisitions to replenish the pack, one for controlled
substances and one for the non-controlled substances.
a. The repackaging technician will forward the controlled substance refill
request to the narcotic vault for replenishment
i. The narcotic vault technician will pull the amount documented on
the charge form
ii. The narcotic vault tech will deliver the medications to the repack
area
iii. The repackaging technician will verify the amount pulled to the
amount document on the form, and then sign the narcotic vault issue
receipt. The receipt is given back to the narcotic vault technician.
iv. The repackaging tech will replenish the narcotic medications
immediately.
b. The repackaging technician will forward the non-controlled substance
refill request to the carousel technician to pull non-narcotic medications to
be replenished in the Case Pack.
i. The carousel technician will deliver all non-narcotic medications to
the repackaging technician.
c. The repackaging technician will replenish the Case Pack and record the
Case Pack number and lock number on the accountability log form.
4. The repackaging technician will request a pharmacist check.
5. The central pharmacist will verify the contents of the replenished Case Pack(s) to
ensure all medications are restocked correctly.
6. Central pharmacist will document the verification on the Box, Case Pack, Kit,
Tray Accountability Log located in Central Pharmacy.

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 5
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA

7. Once the Case Packs are checked by the pharmacist, they are forwarded to the
narcotic vault to be restocked.
8. The narcotic vault technician will audit the number of packs received from the
pharmacist for restocking against the number of packs issued to the pharmacy
technician.

F. Pharmacy technician staff will ensure that the appropriate charging forms are completed
for each used Case Pack.
1. The pharmacy office staff picks the forms up daily and charges used medications
to the appropriate patient within the HealthLink system using the bulk charge
function.
2. After completing the patient billing the pharmacy office forwards yellow copies
of the charge forms to the narcotic vault technician who will match the charge
forms to the issue documents that were completed during the restocking process
and staple together with the daily narcotic packet to maintain the audit trail for the
dispensing.

G. Daily Case Pack Audits
1. Nursing staff will document on the Audit Form the lock number for all Case
Packs at the beginning of each AM and PM shift, and check the integrity of the
Case Packs.
2. If a Case Pack is missing or seal is not intact, a discrepancy form must be filled
out by the nurse who discovers the problem.
3. The nurse will contact the pharmacy technician for assistance in completing the
discrepancy form and to turn in the completed discrepancy form.
4. The nurse will document on the audit form when a Case Pack is removed from its
location. Documentation will also occur when the Case Pack is returned.
5. Daily, the pharmacy technician will audit the Case Pack to ensure that all packs
are properly sealed and documentation is complete.
6. If a pack is open the technician will ensure that there is a corresponding charge
form completed, in addition to verifying appropriate documentation on the audit
form.
7. If a charge form is not completed and/or the audit form the technician will contact
staff to locate a charge form and complete documentation on the audit form.
8. If a charge form is not located a discrepancy report is completed.

POLICY & PROCEDURE





Effective Date:

Dec 2003
Pharmacy Policy Manual
Chapter: Clinics
Operations Procedure Manual
Chapter:

Policy #: 15.6


 Revision
3/2017

Page 6
of 6

Title: Critical Care Case Pack Systems
Supplied to Med Flight and CHETA

9. For dispensed controlled substances documented on the charge form the
technician will verify the amount administered and amount wasted (if any) equals
the amount dispensed. A discrepancy report is completed if any variances exist.
The pharmacy technician will collect Audit Forms every Monday and give the
forms to the narcotic vault.

H. Quality Control and Expiration Checks
1. Daily quality control checks are performed as discussed in F. above.
2. Case Packs are checked and updated for current expiration dates monthly.
3. The integrity of the Case Packs is checked by nurses to ensure that all Case Packs
are locked and secure.
4. Each week a new audit form is used for documentation. The completed audit
forms are returned to the Pharmacy Technical Supervisor. The forms are audited
to ensure that appropriate documentation has occurred.
5. The Pharmacy Technical Supervisor will forward issues to the Critical Transport
Supervisor as needed.
6. Documents will be forwarded to the narcotic vault for filing.

V. COORDINATION:
1. AUTHORED BY: Pharmacy Manager, Patient Care Services & Emergency/Disaster
Preparedness
2. REVIEWED BY: Critical Care Transport Operations Committee
3. COMMITTEE APPROVAL BY: Inpatient Managers Committee



Approved By: __________________________
Director of Pharmacy Services

Date:_______________