/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/controlled-substances/,

/policies/clinical/uwhc-clinical/department-specific/pharmacy/controlled-substances/712.policy

20150234

page

100

UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Controlled Substances

Controlled Substances - Ambulatory Procedure Center (7.12)

Controlled Substances - Ambulatory Procedure Center (7.12) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.12







Effective Date:

April 2007
⌧Pharmacy Policy Manual
Chapter: Controlled Substances
Operations Procedure Manual
Chapter:

Policy #: 7.12

…Original
⌧ Revision 4/14
Page 1
of 2
Title: Controlled Substances – Ambulatory
Procedure Center (APC)

I. Purpose: To establish a safe, reliable and uniform method of ordering, storing, dispensing,
returning, and wasting of Drug Enforcement Agency (DEA) controlled substances (CS) in
the University of Wisconsin Hospitals and Clinics (UWHC) Ambulatory Procedure Center
(APC). To be compliant with federal and state laws governing controlled substances.

II. Policy: Controlled substances used in the APC for gastroenterology and bronchoscopy
procedures are obtained by nursing staff from the APC Acudose Cabinet and stored in
procedure rooms in locked cabinets. APC staff document usage and wastage of these
supplies using manual documentation systems that are audited daily by the Outpatient
Surgery Center (OSC) pharmacy technician.

III. Forms
A. Narcotic Sign Out Sheet: GI Procedure Room

IV. PROCEDURE:
A. CS Dispensing Systems
1. The APC staff will keep a perpetual inventory of controlled substances locked in a
drawer in each APC procedure room.
2. At the beginning of the AM shift the RN will start a new sign out sheet for that day.
3. The RN will verify the beginning balance and initial sign out sheet.
4. As each dose is dispensed from the locked drawer, the RN will document on the sign
out sheet the patient name, MR#, medication dosage administered, and medication
wasted on this form.
5. At the end of the day the RN will take this form and perform a dispense transaction in
Acudose for each medication administered to a patient.
a. The RN will select the “Patient name” from the look-up, select the “medication”
then select “dispense”.
b. The RN will dispense the entire syringe/vial from the Acudose cabinet regardless
of the amount administered to the patient, thus the perpetual inventory will be at
the correct standard.
c. If a dose is entirely wasted, the RN will direct the OSC Pharmacy Technician to
credit the dose.
i. Note: To replace the inventory the dose must be issued and charged to a
patient through AcuDose even if it is wasted completely. A credit will be
done by the OSC Technician so correcting patient billing results.
6. The RN will then remove the medication from the Acudose cabinet and restock the
medication in the locked drawer bringing the inventory to standard for that drawer.








Effective Date:

April 2007
⌧Pharmacy Policy Manual
Chapter: Controlled Substances
Operations Procedure Manual
Chapter:

Policy #: 7.12

…Original
⌧ Revision 4/14
Page 2
of 2
Title: Controlled Substances – Ambulatory
Procedure Center (APC)

B. Destruction of CS Waste from APC
1. Narcotic wastage will be recorded on the sign out sheet.
2. Two RN signatures are required to sign the sign out sheet for each waste event.

C. Verification of Administration and Waste Documentation and Acudose Dispensing
1. At the end of the day, the APC RN will place the sign out sheet in the clinic charge
bin for Pharmacy.
2. The Pharmacy technician will audit this form for accuracy and accountability.
a. The Pharmacy technician will verify that the patient information on the sign out
sheet matches the dispense from the Acudose cabinet.

D. Restocking of the GI AcuDose Cabinet
1. A Pharmacy technician will be responsible for restocking the Acudose cabinet daily.



Approved By: ____________________________
Director of Pharmacy Services

Date: ____________