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/policies/clinical/uwhc-clinical/department-specific/pharmacy/controlled-substances/717.policy

20160363

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

Cactus Smart Sink Operations (7.17)

Cactus Smart Sink Operations (7.17) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.17

POLICY & PROCEDURE





Effective Date:
Jun 2015


☒Pharmacy Policy Manual
☐Operations Procedure Manual

Policy #: 7.17

☐Original
☒Revision
Nov 2015

Page 1
of 4

Title: Cactus® Smart Sink®
Operations


I. PURPOSE
A. To describe the procedures associated with controlled substance waste disposal using the Cactus
Smart Sink.

II. DEFINITIONS
A. Cactus® Smart Sink®
1. This disposal system is designed to be an alternative to a sink or sewer when disposing of
controlled substance waste. The primary purpose is to render controlled substance waste
non-retrievable and discourage the practice of disposing pharmaceutical waste into the
environment. The Cactus® system is a cabinet secured by a locking bracket and key lock
system. The locked cabinet holds disposable liquid and solid cartridges until the replaceable
cartridges have reached their capacity or expire.
B. Non-retrievable
1. As defined by the Drug Enforcement Administration non-retrievable means to permanently
alter any controlled substance’s physical and/or chemical state through irreversible means in
order to render that controlled substance unavailable and unusable for all practical purposes.

III. POLICY
A. SYSTEM UTILIZATION
1. All UWHC employees who waste controlled substance medications shall utilize the Cactus
Smart Sink® to dispose of controlled substance medications.
2. Areas without a Cactus® will dispose of controlled substance waste in the sink or sewer.
B. SYSTEM MAINTENANCE
1. The Cactus® shall be maintained by the pharmacy department.

IV. PROCEDURE
A. ACCESS/SECURITY
1. Access to Cactus® cartridges will be strictly maintained to ensure that only authorized
personnel can receive, access, issue, return, and remove disposable cartridges to or from the
secure storage area.
a. All new pharmacy employees with job responsibilities pertaining to Cactus®
maintenance should have badge access to the storage room approved by pharmacy
administration as outlined in pharmacy policy 1.29 - Security Management Systems
for Medication Storage, Preparation and Dispensing Areas for UWHC.
2. To maintain the integrity of the controlled substance medication use process a database will
be utilized to keep a perpetual inventory of all disposable cartridges from time of facility
arrival to time of reverse distribution pickup.

POLICY & PROCEDURE





Effective Date:
Jun 2015


☒Pharmacy Policy Manual
☐Operations Procedure Manual

Policy #: 7.17

☐Original
☒Revision
Nov 2015

Page 2
of 4

Title: Cactus® Smart Sink®
Operations

a. All new pharmacy employees with job responsibilities pertaining to Cactus®
maintenance should have their employee information entered into the database by
pharmacy administration.
b. The database will utilize the unique barcode identifier on each individual cartridge for
tracking purposes.
c. All persons interacting with the database must scan their employee identification
badge to complete transactions within the database.
3. Keys to the Cactus® Smart Sink® shall be managed in accordance to Pharmacy Policy 1.45
Management of Pharmacy Keys
B. RECEIVING INVENTORY
1. When new cartridges are delivered, the assigned pharmacy technicians must follow the
workflow defined for the receiving facility (e.g., CSC, DHC, TAC, Rehab). – see Appendix
A.
2. The invoice must be obtained for each shipment when product arrives from the vendor.
3. Each received cartridge must be scanned into inventory utilizing the Cactus® database.
Refer to the Cactus® database user guide.
4. The technician must indicate whether each cartridge is a SOLID or LIQUID cartridge upon
entry into inventory.
5. When each cartridge has been added to inventory utilizing the Cactus® database an
inventory received report must be printed, compared to the invoice, initialed, stapled to the
invoice, and added to the daily narcotic packet.
6. If a cartridge was issued out of inventory and not used (or activated if solid) it should be
added to inventory utilizing the Cactus® database so that is can be issued again. Refer to
the Cactus® database user guide.
C. ISSUING/RETURNING CARTRIDGES
1. When cartridges in the Cactus® Smart Sink® need to be exchanged, the assigned pharmacy
technicians must follow the workflow defined for the affected facility (e.g., CSC, DHC,
TAC, Rehab) – see Appendix A.
2. Technicians will be notified via phone when a Cactus® cartridge needs to be exchanged.
3. Before the conclusion of each shift the technician notified by phone is responsible for
exchanging the requested cartridge.
4. Each cartridge issued must be scanned out of storage inventory utilizing the Cactus®
database. Refer to the Cactus® database user guide.
5. Solid Cactus® cartridges require activation prior to use. A pharmacist must activate the
cartridge by adding 1,000 ml of water to the cartridge. The activation of the cartridge must
be recorded by the pharmacist utilizing the Cactus® database. Refer to the Cactus®
database user guide.
6. Each used cartridge returned must be scanned into the storage room utilizing the Cactus®
database.
D. REMOVING CARTRDGES FROM THE SYSTEM

POLICY & PROCEDURE





Effective Date:
Jun 2015


☒Pharmacy Policy Manual
☐Operations Procedure Manual

Policy #: 7.17

☐Original
☒Revision
Nov 2015

Page 3
of 4

Title: Cactus® Smart Sink®
Operations

1. When the reverse distributor arrives to pick up used cartridges, the assigned pharmacy
technicians must follow the workflow defined for the affected facility (e.g., CSC, DHC,
TAC, Rehab) – see Appendix A.
2. Each cartridge must be scanned out of the system utilizing the Cactus® database. Refer to
the Cactus® database user guide.
3. When each used cartridge has been removed from the system a cartridges destroyed report
should be printed, initialed by the technician and the reverse distributor employee, and
added to the daily narcotic packet.
E. INVENTORY CONTROL
1. At least monthly the inventory of unused cartridges will be assessed for replenishment.
a. Run the cartridge in use report.
b. Order the number of solid and liquid cartridges needed to replenish inventory back to
determined par levels.
c. Note: Cartridges can only be ordered in quantities of four.
F. BEYOND USE DATES
1. Solid cartridges are given a beyond use date of one year from time of activation with water.
2. Every month the pharmacy technician with inventory control responsibilities will assess the
solid cartridges soon to be expired.
a. Run the cartridge in use – days since issued report.
b. Count the number of solid cartridges in use past 335 days.
c. Include this number of solid cartridges in the next purchase order.
3. The database must be utilized during this exchange process.
G. INVENTORY AUDITS
1. A weekly audit must be performed to confirm the inventory of all unused cartridges in
storage.
a. Run the inventory report from the Cactus® database.
1) Compare actual versus system counts and resolve all discrepancies.
2) To investigate and resolve count problems utilize the system reports to
determine the most likely reason for incorrect inventory counts.
3) A discrepancy form will be prepared for any cartridges that are not properly
accounted for.
4) After completing the audit and adjusting all discrepancies, the technician will
sign the inventory report and add to the daily narcotic packet.
b. Run the solid in use without pharmacist signoff report.
1) Investigate any solid cartridges installed that do not have documentation that
pharmacist verified addition of water.
H. TROUBLE SHOOTING
1. Refer to the Cactus® Smart Sink® instruction manual located in the cartridge storage area
for trouble shooting issues with equipment.

POLICY & PROCEDURE





Effective Date:
Jun 2015


☒Pharmacy Policy Manual
☐Operations Procedure Manual

Policy #: 7.17

☐Original
☒Revision
Nov 2015

Page 4
of 4

Title: Cactus® Smart Sink®
Operations

2. Contact pharmacy administration for irresolvable issues with equipment or issues with the
database.


V. APPENDICES
A. Appendix A - Workflow by location (CSC, DHC, TAC, & Rehab)

VI. REFERENCES & RELATED DOCUMENTS
A. Cactus Database User Guide
B. Pharmacy Policy 1.29 - Security Management Systems for Medication Storage, Preparation and
Dispensing Areas for UWHC
C. Pharmacy Policy 1.45 - Management of Pharmacy Keys

VII. COORDINATION
A. AUTHORED BY: Sarah Emanuele, PharmD
B. REVIEWED BY: Dave Musa, Pharmacy Manager.
C. COMMITTEE APPROVAL BY: Pharmacy Operations Committee, Inpatient Managers





Approved By: Director of Pharmacy Services
.


Date: