/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/713.policy

201506162

page

100

UWHC,

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

Controlled Drug Distribution and Management for the UW Athletic Department (7.13)

Controlled Drug Distribution and Management for the UW Athletic Department (7.13) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.13





Effective Date:

December 2006

 Pharmacy Policy Manual
Chapter: Controlled Substances

Chapter:

Policy: 7.13

Original
Revision 6/15

Page 1
of 3

Title: Controlled Drug Distribution and
Management for the UW Athletic
Department.


I. POLICY: The University of Wisconsin Hospital and Clinics (UWHC) Department of
Pharmacy will manage the distribution and oversight of controlled drugs used by the
University of Wisconsin Athletic Department (UWAD).

II. PROCEDURE:
A. Controlled substances used by the UWAD will be maintained in a secure safe.
1. The combination to the safe will be known only to UWAD physicians and UWHC
Staff.
2. A prescription will be completed prior to dispensing any scheduled medications and
will be signed by the UWAD physician with all required elements including:
a. Patient’s name and address
b. Medication name, quantity, and directions for use.
c. UWAD physician signature and DEA#.

3. All dispensing of controlled substances will be done by a UWAD physician.
a. All controlled substances dispensed by the UWAD physician will be
administered in the UWAD Sports Medicine Clinic and may not be provided
to patients to self administer.
b. The UWAD physician will record the dispensing on the Controlled Substance
Perpetual Inventory Record (see below).

4. Perpetual inventory records will be maintained by the UWHC Pharmacy Department
and by the UWAD using the Controlled Substance Perpetual Inventory Record (see
below).
a. Prescriptions for UWAD dispensing will be kept on file in the UWAD Sports
Medicine Office.
b. Copies of the prescriptions will also be kept in the UWHC Department of
Pharmacy.
c. Supplies delivered to the UWAD will be added to perpetual inventory records
at both UWHC and UWAD.
i. Additions to inventory will be co-signed by a UWAD physician or
designee and a UWHC employee (witness) on both UWAD and
UWHC records.
d. Supplies issued to patients pursuant to a prescription from a UWAD physician
will be subtracted from perpetual inventory records with details of the
dispensing or administration recorded on the perpetual inventory record
including date dispensed (or administered), UWAD prescription number,
patients name, physicians name, quantity dispensed (if applicable), ending
balance, physicians signature and witness signature (required for CII waste).
i. Wasted quantities of Schedule II narcotics will be recorded on the
perpetual inventory form and a witness will verify the amount that was





Effective Date:

December 2006

 Pharmacy Policy Manual
Chapter: Controlled Substances

Chapter:

Policy: 7.13

Original
Revision 6/15

Page 2
of 3

Title: Controlled Drug Distribution and
Management for the UW Athletic
Department.

wasted. Witness needs to be a licensed individual (MD, Licensed
Athletic Trainer).
e. On a periodic basis the inventories at the UWAD will be reconciled to verify
actual physical quantities match the amount listed on the UWHC and UWAD
perpetual inventory records.


5. On a periodic basis UWHC staff will review inventories of controlled substances at
the UWAD and issue medications from the NarcStation to UWAD based upon pre-
determined minimum and maximum levels for each controlled substance and each
inventory location.
a. For schedule II controlled substances, a DEA form 222 must be completed by
the UWAD physician.
i. The UWHC staff member will contact the UWAD physician to notify
them of the need to complete a DEA form 222.
ii. The UWAD will send to UWHC Department of Pharmacy a
completed DEA form 222.
 Note: All elements of the form 222 must be completed and an
appropriate signature by either the DEA registrant or an
individual granted legal power of attorney to sign DEA form
222 order forms.

iii. After receipt of a complete DEA form 222, the UWHC staff member
will issue the schedule II medication.
b. For other scheduled medications, no order form will be required.
c. Billing to UWAD for controlled substances will be done with each issue using
the UWHC Peoplesoft financial system handling each transaction as a Sale
through NarcStation.

6. On a periodic basis, the inventory records from the UWHC and UWAD will be
audited to ensure all transactions have been recorded properly by a UWHC Pharmacy
Manager.


Approved By: ____________________________
Director of Pharmacy Services

Date: ________________



Controlled Substance Perpetual Inventory Record
University of Wisconsin Athletic Department

Medication ________________________________ Inventory Location __________________

Date Prescription
Number
Patient Name
(print)
Physician Name
(print)
Qty
Dispensed
(or added)
Wasted
Amount
Balance Physician
Signature
Witness
Signature
(required
for waste
and
restocking)