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NarcStation Operations (7.1)

NarcStation Operations (7.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.1





Effective Date:

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Pharmacy Policy Manual
Chapter: Narc Station Operations

Chapter:

Policy #: 7.1


 Revision 8/16

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Title: NarcStation Operations

I. Purpose: To outline the processes associated with ordering, receiving, issuing and returning controlled
substances using the NarcStation System.

II. Policy: The pharmacy will utilize an automated dispensing system, NarcStation, for managing distribution of
controlled substances throughout the University of Wisconsin Hospital and Clinics (UWHC).

III. Procedure:
A. Purchasing
1. Purchasing staff create a purchase order using the Peoplesoft system and forward to the vendor.
2. For schedule II purchases either a DEA form 222 or a Controlled Substance Ordering System (CSOS)
electronic order is created and then signed by an authorized individual.
3. The blue copy of the form 222 or a printed version of the CSOS order is provided to the NarcStation
Technician.
4. For Schedule III-V products a copy of the purchase order will be provided to the NarcStation Technician.

B. Receiving
1. Schedule II Products
a). Stockroom staff receives narcotics from vendor in Peoplesoft system and give the drugs to the
NarcStation Technician along with the invoice and purchase order.
b). The NarcStation Technician receives the drugs into inventory in NarcStation.
c). The NarcStation Technician generates a NarcStation Receiving (secure/working) Report from
NarcStation listing the following for each item ordered:
i. Item #, Description, NDC, Package Size, Qty Ordered, Qty Received Working, Qty Received
Secure.
d). For all CSOS orders the NarcStation Technician completes the receiving in McKesson Connect, saves
a copy of the final CSOS pdf document in the J:\rx\rxshare\CSOS Archive folder, and prints a copy to
include with other receiving documents.
e). The NarcStation Technician paper clips together the NarcStation Receiving (secure/working) Report,
the DEA form 222, the Peoplesoft purchase order, and the invoice from McKesson and delivers to the
CUD pharmacist for review and completion.
i. For CSOS orders a copy of the McKesson purchase order report is printed as a hard copy
equivalent to the DEA form 222.
f). The Pharmacist verifies the NarcStation Receiving (secure/working) Report and returns to NarcStation
Technician for inclusion in daily documentation.
i. Items and quantities received matches McKesson invoice and physical quantities received.
ii. Completes DEA 222 form indicating the date and quantity of drugs that were received.
iii. For CSOS orders quantity and date received is noted on the hard copy of the McKesson
purchase order report.
iv. Signs each line that was received on the Receiving Report.
v. Follows up with NarcStation Technician as needed for any discrepancies.

2. Schedule III-V Products
a). Stockroom staff receives narcotics from McKesson in Peoplesoft system and gives the drugs and the
Rx Copy of the Invoice to the NarcStation Technician.
b). The NarcStation Technician receives the drugs into inventory in NarcStation.
c). The NarcStation Technician generates a NarcStation Receiving (secure/working) Report from
NarcStation listing the following information:
i. Item #, Description, NDC, Package Size, and Qty Ordered, Qty Received Working, Qty
Received Secure.





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d). The NarcStation Technician paper clips together the NarcStation Receiving (secure/working) Report,
the purchase order and the invoice from McKesson and delivers to the CUD pharmacist for review
and completion.
e). The Pharmacist verifies the NarcStation Receiving (secure/working) Report and returns to NarcStation
Technician for inclusion in daily documentation.
i. Items and quantities received matches McKesson Invoice and physical quantities received.
ii. Pharmacist will sign each line that was received on the NarcStation Receiving (secure/working)
Report.
iii. Follows up with NarcStation Technician as needed for any discrepancies.
3. The following items will be provided to the Pharmacy Purchasing Office after steps 1 & 2 above have been
completed.
a). All CSOS and Form 222 documents that have been completely received.
b). All NarcStation Receiving (secure/working) Report
c). All purchase orders and invoice documents.
d). The Pharmacy Purchasing Office will keep item a & b above on file to fulfill DEA document retention
requirements and to facilitate auditing.

C. Ordering Stock from Production Areas (SPA, Repackaging or Manufacturing)
1. If needed, the NarcStation Technician will issue enough raw materials to production area (SPA, Repack,
Mfg.) to prepare the amount of product needed.
a). The receipt must be signed by the staff member from the production area who receives the drug.
b). The open transaction in NarcStation related to the issue is witnessed by the receiving staff member:
i. For issues to SPA, NarcStation technician and witness will verify the addition to the SPA
narcotic log.
ii. For issues to Repackaging and Manufacturing the NarcStation Technician and the witness will
verify that all items issued are properly accounted for as receipt of finished product into
NarcStation.
c). The preparation area prepares the items requested by the NarcStation Technician.
d). If wastage occurs during the preparation of the product, a discrepancy form will be filled out and
given to the NarcStation Technician explaining the reason for the discrepancy.
e). The production area will give the completed products to the NarcStation Technician.
f). The open transaction in NarcStation related to the return of the finished product to the NarcStation
Technician will be witnessed by the returning staff member verifying that the medication is stocked in
NarcStation.
g). The NarcStation Technician will enter the produced items into NarcStation as a return (see section D).

D. Returning Medications
1. The NarcStation Technician creates the transaction using the "Return" selection from the main menu and
enters the following
a). Unit returned from.
b). Drug being returned
c). Quantity returned.
d). Enter the following information in the returning note:
i. Name of technician who returned the controlled substance.
ii. The quantity that was returned.
iii. The Location Name from where the controlled substance came from (e.g. SPA, Repack, RR,
B6/6, F4/5, etc)





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2. When NarcStation Technician is not available, drug returned and a discrepancy report may be placed in the
NarcStation returned medication drop box. In AM, the NarcStation Technician will obtain drug and
discrepancy report from the drop box and document return as noted above.
3. The open transaction in NarcStation related to the return of product to the NarcStation Technician will
be witnessed by the returning staff member verifying that the medication is stocked in NarcStation.

E. Processing Outstanding Issues
1. The NarcStation Technician opens each outstanding issue using the "Return" selection from the main
menu.
a). Select the issue to process
b). The unit returned from, drug, returning qty will automatically populate from the transaction being
processed
c). Enter the reason the item is being returned in the returning note including the following
information:
i. Name of technician who returned the controlled substance and/or restocked the controlled
substance at a location other than the one it was issued to.
ii. The quantity that was returned and/or restocked.
iii. The Location Name from where the controlled substance came from and/or was restocked to
(e.g. SPA, Repack, RR, B6/6, F4/5, etc)
2. If outstanding issue requires drug to be wasted, a discrepancy report will be completed.
a). NarcStation Technician will close outstanding issue as outlined above and include the following
information in the return note:
i. “Drug given to SPA pharmacist for wasting”.
b). After closing outstanding issue, drug and discrepancy report are given to SPA pharmacist who will
destroy medications as outlined in policy 7.9 (Destruction of Scheduled II Narcotics)
c). The SPA pharmacist and a witnessing pharmacist will destroy medications and document
destruction on the discrepancy form including signature of witness pharmacist, and return
discrepancy form to NarcStation Technician.
3. The open transaction in NarcStation related to the open issue will be witnessed by a second staff
member verifying that the disposition of the medication is appropriate and document in NarcStation.

F. Stocking AcuDose Cabinets
1. NarcStation Technician generates “daily issues” poll process for routine restocking of AcuDose cabinets.
a). Click the Daily Issues Option from NarcStation Main Screen.
b). Poll Unit Requests to generate unit order requests.
c). Select all classes of scheduled medications.
d). Select units to fill (see scheduled posted in NarcStation work space).
e). Manage any “out of stock” issues before finalizing transactions.
f). Change quantities as desired to standard issue amounts (full packages)
g). Apply restock bar code labels to issued products to allow AcuDose technician to use bar code
restocking of cabinets.
2. NarcStation Technician will add additional items by unit as needed that were not requested automatically
using manual issue process.
3. Technician who receives the controlled substance will double check all issues from Narc Station.
a). Record initials on Automatic Daily Routine Fill Delivery Check List and leave with the vault
Technician confirming that they received all medications.
4. New orders for Narcs not stocked in AcuDose
a). NarcStation staff or Central RPH will provide the drug to the appropriate technician.
b). The technician will sign the “issue sheet” to leave in NarcStation documentation bin.





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c). The technician will stock new product in the AcuDose cabinet.
5. NarcStation Technician verifies that all items issued to AcuDose Cabinets were stocked in cabinet and that
any returns from cabinets have been stocked back into NarcStation.
a). If there are open transactions, the NarcStation Technician will follow up to resolve the
discrepancies. If the discrepancy cannot be resolved, a discrepancy report will be completed,
and the open transaction will be closed.
.Note: This includes drugs returned by AcuDose technician as part of the daily return bin
audit and all items unstocked as “expired” items.
6. Each day all of the signed Automatic Daily Routine Fill Delivery Check Lists and the Open Transactions
Report will be stapled together and forwarded to the Pharmacy Manager.

G. Issuing Drugs to Specific Patients
1. Drugs may be issued to specific patients but billing must be done using the pharmacy information system.
a). Medications cannot be manually issued without a physician order.
b). Issuing to specific patient will be limited to the following areas:
i. Any area without an Acudose cabinet.
ii. Perioperative areas
iii. Procedural areas
iv. The American Center (TAC) for patient specific preparations
2. Select “Manual Issues”, the desired drug, and unit.
3. Select the “Drug is going directly to patient” checkbox.
4. Enter the patients name and medical record number.
a). For patient specific preparations at TAC also enter the order number.
5. A “Controlled Substance Administration Record (CSAR)” will print automatically.
a). Apply label generated by HealthLink order entry to CSAR.
6. The following elements must be completed on the CSAR by the RN receiving and administering the
medications.
a). Date, Time, Patients Name, Room Number, Nurse, and Amount Given (Amount Wasted, and
Wasted Initials are required for partial dose administration).
7. The NarcStation Technician will prepare a discrepancy report if the completed CSAR is not returned.
8. The open transaction in NarcStation related to the manual issue will be witnessed by a second staff
member verifying that the disposition of the medication is appropriate including all completion of all
required elements outlined in this section.

H. Issuing Drugs to Clinic Narcotic Box and Operating Room Inventories
1. Clinic Narcotic Boxes
a). The Clinic Narcotic Box will be set up in the system as a non-automated unit.
b). The NarcStation Technician will review accountability documents that are accompanying each
box and ensure that all doses have been properly recorded and accounted for.
i. A discrepancy report will be prepared for any doses that are not properly accounted for.
c). The NarcStation Technician will then refill each box to the predefined standard level for each
narcotic using the “Daily Issues” process and provide a receipt for the technician who will receive
the box.
d). The technician who uses the box will verify that the amount stocked in the box matches the
amount on the receipt by reviewing the narcotic accountability documents from the prior day. The
technician will sign the receipt and return it to the NarcStation Technician confirming that the
restocking function was correct and that all drugs issued from NarcStation were added to the box.

2. Operating Rooms





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a). Each operating room satellite maintains a standard level of narcotics.
b). Once each day the operating room technician will order narcotic drugs to refill supply to standard.
c). The NarcStation Technician will review accountability documents daily from the operating rooms
to ensure that all doses issued from NarcStation have been properly documented on the OR
narcotic documentation forms.
3. The open transaction in NarcStation related to the issue of medication to the Operating Room and
Clinics will be witnessed by an OR technician for OR issues or a Clinic technician for clinic issues
verifying that the medication is properly documented.

I. Issuing Drugs to the Sterile Products Area (SPA)
1. Only the SPA Pharmacist may request narcotic drugs from the NarcStation Technician.
2. The NarcStation Technician or SPA Pharmacist will issue the requested drugs to the SPA using the
“Daily Issues” process.
3. The SPA Pharmacist will add a line to the SPA Narcotic Accountability Record for each item received
and initial this entry indicating quantity added and ending balance on the form.
4. The NarcStation technician will verify that the entry has been made on the SPA Narcotic
Accountability Record and that the pharmacist has initialled the entry.
5. The open transaction in NarcStation related to the issue of medication to the SPA will be witnessed by
a second pharmacy staff member verifying that the medication is properly documented on the SPA
Narcotic Accountability Record.
a). Ideally the witness is the pharmacist at the time the product is received.
6. On a daily basis, the NarcStation Technician will review the accountability documents in the SPA from
the previous day to verify the following items:
a). All issues from NarcStation appear on the SPA accountability documents.
b). All C-II infusions prepared have a valid location for final dispensing.
c). All C-II infusions dispensed have valid signature of individual who received product.
d). All C-II infusions dispensed to AcuDose cabinets have corresponding entry showing receipt to
cabinet.
i. For narcotic drips issued to AFCH locations, the NarcStation Technician will call the AFCH
technician to ensure that all drips prepared for AFCH from both SPA and AFCH pharmacy
locations are accounted for.
e). Verify that all drugs listed as SPA stock preparations have been restocked to NarcStation.

J. Issuing Drugs to Ambulatory Pharmacies, Researchers or Loan Borrow accounts
1. The requesting individual will complete a request for narcotic drugs (279 form, loan borrow form, or
OrdeRx electronic requisition) and a completed DEA 222 form for scheduled II medications.
a). Oncology Pharmacy, Outpatient Pharmacy (OPP) and AFCH Pharmacy do not complete DEA 222
forms as they are CSC locations and use the same UWHC Pharmacy Services DEA#
(AU5235014)
2. The request is given to the stockroom to be entered into the Peoplesoft system and a pick list
generated. No dispensing from NarcStation may be completed without first having a pick list obtained
except for emergency situations.
a). Emergencies situations occur when expecting a patient to wait until stockroom staff are available
to fill the order would not provide good patient care or customer service.
b). Drugs may be issued from the NarcStation using "Manual Issues" to the unit "Emergency
Outpatient Requests" (a pick list will not be necessary for these issues) for OPP requests only.
3. For routine (non-emergency) orders, the NarcStation Technician will issue the requested drugs to
customer using the “Sale Options” from the NarcStation main screen.
a). Use YYMMDD (i.e. June 5, 2002 is 020605) for the PO number.





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b). No invoice number is used - Enter "NA" into NarcStation.
c). Enter the DEA form 222 number from the requester.
i. Leave blank for Onc Pharmacy, OPP and AFCH Pharmacy.
d). Complete all other customer information that is available.
e). A pharmacist must complete the DEA222 form prior to issuing the medications.
f). A photocopy of the completed DEA222 from will be sent with the order.
4. When picking up the drug the individual receiving the item must sign the receipt which will be filed
with daily NarcStation documentation.
a). For drugs delivered by transportation, the pharmacy staff member who delivers the medication to
transportation will sign and note "Transportation" on the receipt.
5. Researchers must complete the following additional requirements
a). Research Orders may only be issued between the hours of 9AM and 3PM Monday-Friday
excluding holidays.
b). Research orders must be approved by a Pharmacy Manager who will note approved on 279 or
“OrdeRx” order form.
c). Orders without approval may not be filled.
d). Researchers must submit a copy of their current DEA registration certificate and a photocopy of
picture ID (Hospital ID or driver’s license) of the researcher who is listed on the DEA form 222.
e). Only the researchers listed on the DEA form 222 may pick up schedule II narcotics.
f). NarcStation Technician must verify identity of researcher by matching photo ID to person picking
up drug.
g). Completed documents are kept with DEA form 222 for schedule II medications or daily packets
for schedule III-V medications.
K. NarcStation Audits (all reports will be filed with daily documentation)
1. Run the Pharmacy Inventory Report for all towers weekly.
a). Compare actual versus system counts and resolve all discrepancies.
b). To investigate and resolve count problems the narcotic vault Technician will utilize the Station
Event Report to determine most likely reason for incorrect inventory counts.
c). After completing the inventory and adjusting all discrepancies, the NarcStation Technician will
sign the Pharmacy Inventory Report and forward to the Pharmacy Manager.
2. Run the Refill Activity Report Daily (Not submitted with daily documentation. Kept on file in narc file
cabinet).
a). Verify that all narc drips issued from the SPA are placed in AcuDose.
b). Audit all return bins to make sure that items either are restocked to cabinets or that products are
returned to pharmacy as damaged on a discrepancy report.
c). Use report to solve discrepancies that occur such as units not receiving the correct quantity or
other types of issues.
3. Run Assigning & Unassigning Report daily (Not submitted with daily documentation. Kept on file in
narc file cabinet).
a). Verify that narcotic drip returns are given to the SPA or that they were stocked to another cabinet.
4. Check all inventory (including narcotic boxes) for expired medications each month.
a). Document this on appropriate form.

5. Run Wasted Drug List daily.
a). For all wasted drug a discrepancy form must be completed and signed by two licensed pharmacists
when drug is destroyed and must be included in daily documentation to support each entry on the
Wasted Drug List.
6. Documentation of narcotic transactions will be monitored as follows:





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a). The NarcStation Technician will forward the reports outlined on the Narcotic Control
Documentation Checklist to the Pharmacy Manager for review each day.
b). The Pharmacy Manager will review the reports and sign the checklist and follow up on incomplete
or incorrect documentation.
c). After review the Pharmacy Manager will forward the completed documentation to the NarcStation
Technician for filing. Completed paperwork will be maintained for five years following
departmental archiving procedures (see P&P 1.23).
7. Processing Open Transactions
a). The NarcStation Technician will review all open transactions listed on the NarcStation.
b). For any transaction that has not closed, the NarcStation Technician will review the refill activities
report and verify that the transaction was handled correctly.
c). For transactions handled appropriately the NarcStation Technician will close the transaction and
enter the name of technician and disposition of drug in the note field.
d). If it is not obvious from the refill activity report that the drug was handled appropriately, the
NarcStation Technician will follow up with user to determine disposition of drug.
i. If inappropriate disposition or unable to determine disposition of the drug the NarcStation
Technician will close the transaction and enter the name of technician involved, circumstances
related to discrepancy, and notation that discrepancy report has been completed.
ii. A discrepancy report will be completed and provided to the Pharmacy Manager.
e). The open transaction in NarcStation will be witnessed by a second staff member verifying that the
disposition of the medication is appropriate.
8. Run the NarcStation Events by Medication report for event type “Sales” (a report listing all issues via
the "Sale Options") for the week and verify the following
a). Complete documentation as outlined in section J is found to match each entry of the report.
b). The NarcStation Technician will audit all issues to Oncology Pharmacy, OPP and AFCH
Pharmacy.
i. Compare each item listed on the Sales List as issued to the pharmacy with the perpetual
inventory record in each pharmacy.
ii. Verify quantities match.
iii. Initial perpetual inventory record in the pharmacy documenting confirmation of quantity.
iv. Make check mark on Sales List indicating the transaction has been verified.
c). For items for which a discrepancy in item or quantity appears complete the following:
i. Review the discrepancy with managing pharmacist or pharmacist in charge.
ii. Attempt to resolve the discrepancy.
iii. For discrepancies for which resolution cannot be complete prepare a narcotic discrepancy
report (see P&P 7.4).
9. Verify SPA stock items were returned into NarcStation.
a). Review the SPA narcotic logs and verify that items were stocked in NarcStation by review of the
Station Events Report for returns
b). Initial SPA narcotic log for every stock preparation transaction audited.
10. Review the Non-automated Unit Issues Report daily.
a). Verify that all issues from NarcStation to the SPA are recorded on the SPA perpetual inventory
log and initial the log next to the transaction to document this verification.
b). Verify that all issues to Repack and MNF were restocked into the NarcStation.
c). Verify that all issues to retail pharmacies were added to the perpetual inventory logs
d). Verify that all issues to OR areas match OR packet restock amounts.
e). Verify that all issues to AFCH Inpatient Pharmacy were stocked into the AFCH NarcStation.
11. Take Home Prescription Audit
a). Run NarcStation Custom NarcStation Events (By Medication) Report for prior day.





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b). Verify that all Outpatient prescriptions listed on report have prescription and label present.
c). Folllow up on outpatient prescription dispense without prescription labels and complete
discrepancy report if unresolved.
d). Place prescription labels on report.
12. Ansethesia Cabinet Restock Audit
a). Run Anesthesia Narcotic Restock Tracking Report for prior day
b). Verify that all dispenses from NarcStation on Anesthesia Restock Tracking Report are found as
stocked on the Anesthesia Station Events report.
c). Follow up on any missing NarcStation issues for anesthesia cabinets and complete a discrepancy
report if unresolved.
d). Place audit documents in daily packet upon completions

L. Narcotic billing information for hospital financial system.
1. Each transaction (issue or return) must be associated with a pre-defined unit (automated or non-
automated).
2. Each unit is associated with a Peoplesoft billing number or cost center.
3. A cost center can have multiple units (see examples below).
a). All cabinets are in 1365 cost center.
b). Repackaging and SPA are in the 1365 cost center.
c). Researchers have unique account number.
d). Retail pharmacies have unique cost centers.
e). The OR is in 5101 cost center.
4. Each drug has a unique Peoplesoft item number. This will be stored in the ConnectRx database in the
miscellaneous field.
5. Each day the following reports are run in the ConnectRx system:
a). NarcStation Export Report
i. Auto Units – Issues
ii. Auto Units – Returns
iii. Non-Auto Units – Issues
iv. Non-Auto Units – Returns
6. Data will be created listing all transactions with the following fields:
a). Description
b). Issue or Return Value
c). Qty
d). Peoplesoft Item Number
e). Department
7. This information will be uploaded into the Peoplesoft financial system to appropriately allocate
expense to the various cost centers or account numbers.

M. Handling Expired/Wasted/Recalled Medications
1. The NarcStation Technician will enter the expired/wasted/recalled medication into the NarcStation
using the “Waste Expire Recall” button.
a). Select the transaction type, drug and quantity.
b). Enter the NDC, Manufacturer, Manufacturers lot number, expiration date, and a note explaining
the reason for the entry.
c). Select the “Witness” button and have a witness verify the expired/waste/recall transaction.
d). Once the transaction has been completed select the “Save” button and answer “Yes” to remove the
medication from inventory.
i. Place expired medications in the expired bin in the vault.





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ii. Place recalled medications in the recalled bin in the vault (keep a copy of the recall notice with
the recalled medication).
iii. For wasted drug, complete a discrepancy form and have two pharmacists sign, and then destroy
the medication.
e). The NarcStation Technician will run a Wasted Drug List every day and include in the daily
documentation.

2. For expired medication, the Pharmacy will return medication to EXP (the hospital’s reverse drug
distributor.
a). The NarcStation Technician will run the expired drug list and provide the list and expired
medications to the EXP vendor representative.
b). The EXP vendor representative will complete a DEA form 222 for each product returned and for
the amount provided.
c). The NarcStation technician will verify that the form 222 matches the entries on the Expired Drug
List.
d). The NarcStation technician will arrange for return shipment of the expired medications in
coordination with a pharmacy manager.
e). The pharmacy manager will witness the expunging of the expired medications from the
NarcStation.
f). The NarcStation technician will prepare the Expunged Medication report and provide to the
pharmacy manager.
g). The Narcotic Control coordinator will verify that the Expunged Medications list matches the forn
222 for the returned medcations.
h). The Expunged list will be archived with the form 222 for auditing purposes.

3. For recalled medications, complete the appropriate documentation to return the medication as
instructed in the recall notice.
4. The narcotic Technician will run the Recalled Drug List in Bin and the Expired Drug List in Bin
reports every week.
a). The NarcStation Technician will verify that drugs listed on both reports are present in the
NarcStation and resolve any discrepancies.
b). For missing or extra items the NarcStation will prepare a discrepancy report for review by the
Pharmacy Manager.

N. Narcotic Key Security
1. Control of keys that allow access to narcotics in clinics and procedure areas will be maintained by the
Key Watcher system as outlined in Policy1.45 Management of Pharmacy Keys.

O. Return Bin Audit
1. The assigned technician will run the “Return Bin Activities” report every day for each cabinet that is
restocked.
2. The technician will open each return bin with medications that has been returned and record the actual
amount on hand and sign and date the report (for return bins with no items, no signature is needed).
3. The technician will either restock meds from return bin back into the AcuDose cabinet or will return
controlled drugs to the NarcStation Technician (see section D for details on completing the return
transaction).
a). For controlled drugs returned to NarcStation
i. The controlled drug will be placed in a zip lock bag along with the corresponding page of the
return bin audit and returned to NarcStation.





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b). For drugs restocked to the AcuDose cabinet, the medications are placed into the appropriate
pocket by scanning the medication and the report alone is returned to NarcStation.
c). For report pages without controlled drugs to be returned, only the audit documents are provided
4. For any drug that is missing from the return bin audit the technician will complete a discrepancy report
(see pharmacy policy 7.4 Controlled Substance Discrepancy Reporting for details on completing
reports)
a). Note the name of nurses who completed the return bin transaction on the discrepancy report.
b). Print a copy of the transactions related to the missing item using the Stations Events report and
attach to the discrepancy report.
5. The NarcStation Technician will audit all return bin audit transactions, verify the disposition of all
controlled substances, and prepare a discrepancy report for any unresolved discrepancies.

P. Downtime procedures
1. If the NarcStation goes down there are keys locked up in the SPA which may be used to override the
NarcStation cabinets.
a). To open the cabinet complete the following:
i. Place key in lock on left side of cabinet and open all three locks.
ii. Lift lever labeled "F" (there is one lever per door).
iii. This will open the door (open doors as needed).
iv. A list of medications by location is in a binder next to the Narc Station PC.
b). All narcotics issued during the down time will be recorded on the Narc Station Downtime Log.
c). Once the system is restored, the narcotic Technician will enter all transactions that occurred while
the system was down into Narc Station.
d). Signatures on the receipts will be replaced by notation "Issued during downtime".
e). The NarcStation Downtime Log will be turned in with the daily audit forms to the Pharmacy
Manager.

Q. Acudose Cabinet Discrepancy Resolution
1. Nursing staff are responsible for resolving discrepancies created related to the use of Acudose cabinets
for patient care activities.
2. Pharmacy staff is responsible for resolving discrepancies created related to incorrect stocking of the
Acudose cabinets.
a). When a discrepancy is created that is the result of incorrect stocking of the cabinet, the designated
nurse will contact the NarcStation Technician and explain the situation.
i. During hours when a NarcStation Technician is not available, the nurse will leave a message
on voice mail and the NarcStation Technician for the next day will complete appropriate
follow up.
b). The NarcStation Technician will investigate the situation and if a stocking error was made will
resolve the discrepancy.

R. Hospice Orders and Returns
1. Acudose restocking lists must be checked by a pharmacist and a form 222 provided by Hospice when
delivered to the cabinets.
2. Items returned from Hospice must have a form 222 prepared by UWHC for each item provided.
a). Prepare PO using procedure in section B to add items to inventory from Hospice.
b). If item received is expired, then either expire for processing to Capital returns or waste product
using discrepancy form (see section L).

S. Transferring Inventory from Secure to Working





Effective Date:

October 2002
Pharmacy Policy Manual
Chapter: Narc Station Operations

Chapter:

Policy #: 7.1


 Revision 8/16

Page 11
of 11

Title: NarcStation Operations

1. Inventory that is greater than amount allocated for storage in working inventory is placed in secure
inventory when item is received.
2. On a daily basis, the NarcStation Technician will review items in secure inventory and move
appropriate amounts into working inventory.

T. Issues of Schedule II items to the Clinical Laboratory for Testing
1. The clinical laboratory may request items for laboratory testing including the routine analysis of waste
samples from the OR or ad hoc requests.
2. The NarcStation Technician or SPA Pharmacist will issue the requested drugs to the Clinical
Laboratory using the “Daily Issues” process.
a). Issues to Clinical Laboratory will be facilitated by a pharmacy manager.
b). The Clinical Laboratory will maintain a Clinical Laboratory Narcotic Use Record for each
narcotic kept for analytic procedures.
c). Issues will be added into the Clinical Laboratory Narcotic Use Record by the pharmacy manager
and signed by both lab staff and pharmacy staff.
d). Clinical laboratory will document their use on the Clinical Laboratory Narcotic Use Record.

U. NarcStation discrepancies may only be resolved by a Pharmacy Manager
1. The NarcStation technician will notify the pharmacy manager of open discrepancies.
2. The Narcstation technician will research the cause of any discrepancy and provide information to the
manager at the time discrepancy resolution.
3. Any discrepancy that cannot be resolved will be reviewed with the Narcotic Control Coordinator or
Pharmacy Manager of Business Operations.


V. Dispensing Medications from NarcStation for Retail Prescriptions
1. Medications for take home prescriptions will be entered into the pharmacy retail prescription
software.
2. Medication will be dispensed using the Narcstion Outpatient function
a). The prescription number will be entered into the Patient Name Field
3. A copy of the prescription label will be left with the original Rx for auditing (see section K12
above for detail) after medications are removed from NarcStation.


Approved By: ____________________________
Director of Pharmacy Services

Date: ________________