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Validated Pharmacy Technician (VPT) Cart Check Program (3.33)

Validated Pharmacy Technician (VPT) Cart Check Program (3.33) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Decentral

3.33





Effective Date:
September 2005


 Administrative Manual
 Nursing Manual
 Other: Pharmacy

Policy #:
3.33

 Original
 Revision 06/14

Page 1
of 4

Title: Tech Check Tech Program

- 1 -
Purpose: To clearly define the eligibility requirements, training, competency and ongoing quality
assurance for the University of Wisconsin Hospital and Clinics (UWHC) Tech-Check-
Tech (TCT) Program.

Policy: The UWHC TCT program allows trained and validated pharmacy technicians to complete
the final accuracy check for first dose and cartfill medications dispensed from semi-
automated dispensing technology. As required by the Pharmacy Examining Board (PEB),
a pharmacist final check will occur for 30% of all first dose medications and 10% of all
cartfill medications prior to medication delivery to the patient care units. Medications
excluded from the TCT program that always require a pharmacist check for accuracy
include: on demand carousel picks, floorstock restocking forms, and first dose labels not
routed through the carousel processing queues (ex. triage printer). If a VPT is not
available, then a pharmacist must check all doses.

Definitions:
A. VPT – validated pharmacy technician
B. Semi-automated dispensing technology – not fully automated, the technology requires some aspect of
human interaction and manipulation to function
C. First dose medication – initial dose dispensed to a patient care unit upon verification by a pharmacist
for appropriateness
D. Cartfill medication – subsequent doses dispensed to the patient care unit in a batch process prior to the
due time

Forms:
A. UWHC TCT Program Training Manual – Appendix A
B. Practical Training Checklist – Appendix B
C. Competency Assessment Checklist – Appendix C
D. Validation Error Introduction and Tracking Form – Appendix D
E. VPT Validation Error Log Form – Appendix E
F. Cart Fill Log Form – Appendix F
G. First Dose Log Form – Appendix G
H. TCT PEB Submission Report – Appendix H

Procedure:
A. For a pharmacy technician to be eligible for Validated Pharmacy Technician status and participate in
the TCT program, a technician must meet the following conditions:
1. Graduate of an accredited technician training program or at least 3 years of experience as a
pharmacy technician
2. One year of experience in the UWHC inpatient pharmacy with baseline understanding of
packaging, robot, and carousel operations
3. FTE appointment of 0.8 or greater
4. Certified Pharmacy Technician (CPhT)
5. Maintain a minimum performance evaluation score of 3





Effective Date:
September 2005


 Administrative Manual
 Nursing Manual
 Other: Pharmacy

Policy #:
3.33

 Original
 Revision 06/14

Page 2
of 4

Title: Tech Check Tech Program

- 2 -
6. Minimal time and attendance issues as defined by the evaluating manager or supervisor
B. All pharmacy technicians are required to undergo specialized training prior to participation in the TCT
program. Training will consist of the following components:
1. Completion of the Tech-Check-Tech Training Manual (Appendix A)
2. Completion of the final written exam with a score greater than 90%
3. Completion of one-on-one practical training with both pharmacists and/or VPTs (Appendix B)
4. Completion of competency evaluations with a pharmacist (Appendix C)
5. Achievement of 99.8% checking accuracy rate throughout the validation process (Appendix E)
C. Training Structure
1. Didactic training in the UWHC TCT Program Training Manual (Appendix A) is focused on:
a. Medication use process
b. Dosage form recognition
c. Proper labeling
d. Packaging and repackaging techniques
e. Medication safety
f. Basic pharmaceutical calculations
g. Common pharmaceutical abbreviations
2. Practical training is completed with a pharmacist’s oversight and will be based off the practical
training checklist. (Appendix B)
a. After observing and assessing the ability of the pharmacy technician, the training
pharmacist or VPT will provide written and verbal feedback noting additional areas
of training necessary. Each trainer and trainee will be required to initial each item on
the checklist when training is complete.
b. Practical training must be completed on a minimum of three different occasions.
3. Upon completion of practical training, pharmacy technicians will be given a final assessment
by a pharmacist and will be required to satisfy all of the criteria on the competency assessment
checklist (Appendix C).
D. Validation Structure
1. For initial validation the pharmacy technician shall attain a 99.8% accuracy rate for a
minimum of 2,500 consecutive doses over a period of five checking sessions.
a. The training pharmacist is required to double check the contents of each unit dose
medication bag after they are checked by the pharmacy technician. Any errors
determined to be due to the improper checking by the pharmacy technician will be
documented by the pharmacist in order to maintain accuracy numbers to report to the
PEB.
b. Errors recorded will include an occurrence of a wrong drug, dose, dosage form,
extra/insufficient quantity of doses, and omitted medication. Each dose counts as an
error, regardless if it is an identical error or not.
2. During the validation process, the pharmacist evaluating the pharmacy technician will
artificially introduce errors at a minimum rate of 0.2% (5 doses per 2500). The pharmacist
coordinating the audit will keep a record of introduced errors to ensure that all are removed
prior to distribution. (Appendix D)





Effective Date:
September 2005


 Administrative Manual
 Nursing Manual
 Other: Pharmacy

Policy #:
3.33

 Original
 Revision 06/14

Page 3
of 4

Title: Tech Check Tech Program

- 3 -
3. Upon successful completion of the validation where a 99.8% accuracy rate was accomplished,
the pharmacy technician will be recognized as a VPT.
4. If a pharmacy technician cannot achieve the required 99.8% accuracy level in checking 2,500
consecutive doses upon completion of training, the pharmacy technician will not be allowed to
participate in the VPT program.
E. Ongoing Standards for participation in the tech-check-tech program
1. If the accuracy of the VPT is less than 99.8% in any one month they will be required to meet
with the manager of the TCT program to review the errors and a decision will be made if re-
training is necessary.
2. If the accuracy of the VPT is less than 99.8% for two consecutive months or over a six month
period the VPT is required to be re-trained and re-validated.
3. If the accuracy of the VPT is less than 99.8% in two consecutive six month periods, the VPT
will be removed from the TCT program.
4. If the accuracy of the VPT is less than 99% in any one month re-training and re-validation
must occur for continued participation in the program.
5. If a VPT does not check for two consecutive months, re-validation must occur for continued
participation in the program.
6. If a VPT does not check for four consecutive months, re-training and re-validation must occur.
7. If a technician fails re-training or re-validation at any time the VPT will be removed from the
TCT program.
F. Checking Procedure – Cartfill and First Dose Fills
1. Unit dose medications will be filled by the carousel technician and placed in a bag. The VPT
will be required to ensure the contents of the bag match the label placed on the bag. Items
reviewed include correct medication, correct dose, correct dosage form, correct quantity,
expiration date, appropriate packaging and product integrity.
2. A pharmacist will perform a final check of 10% of cartfill medications and 30% of first dose
medications checked by each technician throughout their shift.
a. Certain medications will always require a pharmacist double check prior to delivery
to the patient care units.
b. All errors identified by the pharmacist will be documented in the TCT database,
discussed with the VPT and corrected by the pharmacist prior to delivery of
medications to the patient care units. (Appendix F)
3. Medications excluded from the TCT program that always require a pharmacist check for
accuracy include: on demand carousel picks, floorstock restocking forms, first dose labels not
routed through the carousel processing queues (ex. triage printer) and STAT medications.
4. The pharmacy technician filling the medication from the carousel technology cannot be the
same person performing TCT and verifying the accuracy of the medication fill.
G. Documentation
1. A TCT report will be submitted to the PEB. (Appendix G)
a. A report describing cartfill data from January through June will be submitted no later
than the last day in July.
b. A report describing cartfill data from July through December will be submitted no
later than the last day in January.





Effective Date:
September 2005


 Administrative Manual
 Nursing Manual
 Other: Pharmacy

Policy #:
3.33

 Original
 Revision 06/14

Page 4
of 4

Title: Tech Check Tech Program

- 4 -
c. A quarterly report describing first dose data will be submitted.
2. An internal file will be kept for all VPTs documenting their training and validation.

REFERENCES AND RELATED POLICIES, PROCEDURES: None
COORDINATION:
A. AUTHORED BY: Brad Ludwig
1. REVIEWED BY: Steve Rough
2. COMMITTEE APPROVAL BY: Inpatient Managers


Approved By: ____________________________
Director of Pharmacy Services

Date: ________________