/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/79.policy

201507191

page

100

UWHC,

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

Disposal of Controlled Substances (7.9)

Disposal of Controlled Substances (7.9) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.9





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Controlled
Substances
Operations Procedure Manual
Chapter:

Policy #: 7.9

 Original
 Revision 7/15

Page 1
of 2

Title: Disposal of Controlled Substances


I. PURPOSE: This document outlines the procedures used to comply with DEA requirements
for the destruction of controlled substances.

II. POLICY: The Pharmacy will dispose of controlled substances when appropriate to ensure
safe, legal, and consistent disposition. A pharmacy manager will be involved in the waste
and destruction of all damaged or opened controlled substances from non-retail pharmacy
inventories.

III. PROCEDURE:
A. All controlled substances that require destruction shall be destroyed by a pharmacist or
sent to pharmaceutical reverse distributer.
1. A Pharmacist may waste controlled substances for the following reasons:
a. The item has been damaged, opened or otherwise made unusable for another
patient.
i. All controlled substances damaged, opened or in some way altered from
original packaging found in non-retail pharmacy inventories will be
documented on discrepancy form and placed in the pharmacy controlled
substance drop box.
ii. Items will be reviewed by a manager prior to destruction for evaluation of
circumstances and need for lab testing.
b. The item was prepared for a specific patient and is now not needed due to
discontinuation of the order or the product has expired.
c. The item is an expired oral liquid or injectable medication even if made as stock
and is considered prepared for a specific patient according to DEA regulations.
2. Destruction by a pharmacist will be documented using a discrepancy report or
appropriate form which is co-signed by another pharmacist who witnesses the
destruction. The destruction is done in the presence of both pharmacists who visually
witness the items become non-recoverable.
a. In patient care areas documentation of waste may also be documented by
healthcare professionals who may dispense, administer or prescribe medications.
Documentation of breakage by these personnel is acceptable.
b. Disposal of wasted controlled substances in the Central Pharmacy will take place
within sight of a video camera and drugs made non-recoverable using the
appropriate waste stream.

3. Scheduled items other than those described in section A – 1 above will be sent to a
pharmaceutical reverse distributer including the following items:





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Controlled
Substances
Operations Procedure Manual
Chapter:

Policy #: 7.9

 Original
 Revision 7/15

Page 2
of 2

Title: Disposal of Controlled Substances

a. Partial containers of medications that have expired.
b. Full containers of medications that have expired.
c. Unit dose products prepared for general use in the hospital that has expired.
i. Unit dose oral solids packaged by UWHC staff using standard packaging
procedures are considered unit dose products and must be sent to the return
goods vendor for destruction according to DEA regulations.
B. The University of Wisconsin Hospitals and Clinics (UWHC) has obtained explicit
approval for the use of the Cactus Smart Sink (see appendix A)

IV. REFERENCES AND RELATED POLICIES, PROCEDURES
A. Pharmacy Policy 7.4 – Controlled Substance Discrepancy Reporting
B. Pharmacy Policy 1.23 – Pharmacy Records Retention
C. DEA Pharmacist Manual
D. Appendix A – Email Communication from U.S. Drug Enforcement Administration
(DEA) – Approval of Cactus Smart Sink for Narcotic Waste Disposal.

V. AUTHORED BY: Dave Musa
VI. COMMITTEE APPROVAL BY: None





Approved By: ____________________________
Director of Pharmacy Services

Date: ________________