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Evaluation of Controlled Substance Prescriptions within UW Health Community Pharmacies (7.18)

Evaluation of Controlled Substance Prescriptions within UW Health Community Pharmacies (7.18) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.18






Effective Date:
April 2016
Pharmacy Policy Manual:
Chapter: Controlled Substances
Policy
7.18

 Original
 Revision

Page 1
of 2

Title: Evaluation of Controlled Substance
Prescriptions within UW Health
Community Pharmacies


I. PURPOSE: To provide guidance on the process for pharmacy employees to follow
when evaluating controlled substance prescriptions written by UW Health prescribers.


II. DEFINITIONS
A. Prescription Drug Monitoring Program (PDMP): a statewide electronic database
that collects designated data on monitored prescription drugs dispensed in the
state to help prevent the misuse of prescriptions drugs that are prone to abuse,
support legitimate medical uses of prescription drugs, and allow practitioners and
pharmacists to verify patients’ use of monitored prescription drugs.

III. BACKGROUND
A. The increasing prevalence of prescription drug abuse has reached a public
health risk of epidemic proportions. As the final safety check in the medication
use process, federal regulations explicitly charge the pharmacist with a
“corresponding responsibility” to ensure that controlled substances are dispensed
for a legitimate medical purpose. Furthermore, as medication experts,
pharmacists possess the clinical training to provide effective clinical
interventions. Pharmacists are also well positioned to make effective use of a
variety of monitoring tools including: internal pharmacy dispensing records, third
party drug utilization reviews and prescription drug monitoring programs
(PDMPs).

IV. PROCEDURE
A. Prescriptions for all controlled substances must be reviewed by a pharmacist
prior to dispensing.
B. During the review process, the pharmacist will utilize multiple methods to assess
a prescription has been prescribed for a legitimate medical purpose. These
methods include pharmacy dispensing records, Health Link and the WI PDMP,
conversations with the patient and prescriber.
C. If the pharmacist identifies a concern regarding a controlled substance
prescription, the pharmacist will contact the provider directly to discuss the
concern.
D. If the pharmacist’s concern is not resolved through discussion, the pharmacist
will complete an Internal Controlled Substance Review Form (ICSRF)- Appendix
A and submit it to their direct supervisor.
E. The Ambulatory Pharmacy Leadership Committee will review the ICSRF and if
further review is need, the pharmacy manager will request a peer review of the
prescriber by the physician dyad of the medical clinic and if needed by the Peer






Effective Date:
April 2016
Pharmacy Policy Manual:
Chapter: Controlled Substances
Policy
7.18

 Original
 Revision

Page 2
of 2

Title: Evaluation of Controlled Substance
Prescriptions within UW Health
Community Pharmacies


Review Chair . The pharmacy manager will also assist the Peer Review as
requested with collection of any information to help with the peer review process.
F. The Peer Review Chair will communicate the results of the peer review with the
pharmacy manager and determine what further actions are necessary to ensure
patient care needs are met.


V. COORDINATION:
A. AUTHORED BY: Carrie Boeckelman, RPh, BCACP
B. REVIEWED BY: Joe Cesarz, PharmD, MS, Melissa Ngo, PharmD, BCACP,
Philip Trapskin PharmD, BCPS; Medical Board Peer Review Committee














Approved By: _________________________________
Director of Pharmacy

Date: __________________