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Patients Own Medications Storage and Use (3.5)

Patients Own Medications Storage and Use (3.5) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Decentral

3.5

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 1
of 11

Title: Patient’s Own Medication Storage and
Use

I. PURPOSE: To identify criteria for use of a patient's own supply of medications while an
inpatient and to establish procedures for storing, maintaining adequate supplies, and returning or
disposing of those medications. Refer to policy 8.17 "Administration of Medications" of the
hospital administrative policy and procedure manual for additional information.

II. DEFINITIONS:
A. Controlled Substances: medications that are listed in schedule II, III, IV, or V of the
Controlled Substances Act
B. Patient’s own medication: A supply of medication brought to the hospital by the patient
or the patient’s designee which are taken into pharmacy possession for storage or use
during the patient’s acute care stay.

III. PROCEDURE:
A. Pharmacist notification.
a. Pharmacists may be notified by any member of the healthcare team (e.g.
physician, advanced practice provider, nurse, pharmacy technician, pharmacy
intern) or the patient/patient’s designee of any prior to admission medication
supply the patient has in their possession.
B. Criteria for use:
a. Use of a patient's own medication is permitted if all of the following criteria are
met:
i. An equivalent formulary product is not available, and the medication
cannot be reasonably obtained by the pharmacy department.
ii. The patient, or the patient’s designee, guardian, or legal representative
gives verbal consent allowing the patient’s own medication to be
administered by hospital personnel.
iii. A pharmacist visually identifies the medication and assesses the
medication’s integrity.
b. The pharmacist should inform the prescriber and patient or patient’s designee if
the patient’s own medications brought to the hospital do not meet criteria for use.
C. Patient Self-administration
a. The decision that an inpatient should be responsible for self-administration of
medications is made jointly by the physician, nurse, pharmacist and respiratory
therapist (for aerosolized medications) in consultation with the patient.
b. The medication order should include selection of the "self-administration"
modifier.

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 2
of 11

Title: Patient’s Own Medication Storage and
Use

c. An assessment of the patient's ability to safely and accurately self-administer their
medications, along with patient instruction on the safe self-administration of each
drug, will be completed prior to initiating patient self-administration of
medications. Documentation of this assessment will be entered into the patient's
electronic medical record by the assessor.
D. Storage
a. If patient's own medication will not be used during the hospital stay, it should be
given to a patient’s designee to take home whenever possible
b. For medications that remain at the hospital during the patient’s hospital stay, the
following storage requirements must be followed:
i. If a patient’s own medication is being used during the inpatient stay, a
pharmacist shall ensure:
1. The pharmacists will attempt to identify all medications
2. The pharmacist shall indicate the name, strength and quantity of
the medication and patient’s name, medical record number (MRN),
unit, and date on the Stored Medication Record (See Appendix A).
3. Pharmacists shall keep the original copy of the Stored Medication
Record at the pharmacist’s team support area
4. The pharmacists shall also provide the patient with a copy of the
Stored Medication Record. This record shall be provided to the
patient’s nurse for disbursement
5. Non-controlled medication(s) shall be stored in the patient’s
medication drawer or refrigerator
6. Controlled substances shall be stored in the AcuDose cabinet
according to policy #14.4 in the “Pt’s Own Controlled Substances
FOR USE” pocket.
ii. If a patient’s own medication(s) is only being stored, the pharmacist will
ensure:
1. Pharmacist will attempt to identify medications
2. Pharmacist shall indicate the name, strength, and quantity of the
medication and put the patients full name and medical record
number, unit, and date on the face of the tamper-evident bag of
stored medications (See Appendix A)
3. Stored medications shall be placed in a taper-evident security bag
labeled with the patient’s full name and medical record number
4. The security bag number should be documented on the Stored
Medication Form

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 3
of 11

Title: Patient’s Own Medication Storage and
Use

5. The pharmacist shall also provide the patient with a copy of the
Stored Medication Record. This record shall be provided to the
patient’s nurse for disbursement
6. Controlled substances should be counted by a pharmacist and
another individual prior to sealing in the security bag
7. All medications should be locked in the designated medication
storage cabinet
8. Schedule II and III controlled substances may not be stored at the
patient’s bedside
c. If the patient is in an isolation room, the staff removing the medications from the
patient’s room must wipe down the outside of the containers the medications are
stored in with a Caviwipe.
d. Pharmacist shall note “stored meds” in the patients electronic medical list to alert
all pharmacists that meds are stored at the time of discharge and/or to alert the
receiving pharmacist(s) in case of patient transfer to a different service. The note
should state the location of the stored medications as well as the tracking number
on the tamper-evident bag if multiple bags are stored.
E. Documentation
a. A patient's own medications should be profiled, administered, and charted by the
same procedures governing all other medications given to inpatients at UW
Health with an exception for bar code scanning.
b. The medication order should include selection of the "patient’s own" modifier and
entered into the patient’s computerized medication profile. The “patient’s own”
note will appear on the patient’s medication profile.
F. Maintaining supplies for a patient's own medications to be used as an inpatient.
a. Within 24 hours of receipt of the medications, the pharmacist will assess the
number of days' supply of each for inpatient use patient's own medication
ordered. The pharmacist will document the estimated days supply of the
medication in the administration instructions (e.g. Patient’s own supply is
estimated to be exhausted on “date”, please notify pharmacist 72 hours in advance
of needed resupply)
b. Patients own medication supplies should be monitored during daily distribution of
the medication to the patient by the nurse or designee, who should assess the
current supply of medication and communicate any apparent discrepancies with
estimated exhaustion date to the unit pharmacist immediately.
c. Seventy-two hours before the patient's own medication supply is depleted; the
nurse should communicate the supply to the pharmacist. The pharmacist will

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 4
of 11

Title: Patient’s Own Medication Storage and
Use

contact the resident or attending physician regarding the status of the patient's
own medication. At that point the options will be to a) special order the
medication via the special order process, b) change the medication order to a
formulary alternative or, c) request that the patient acquire a refill of the
medication. The determination should be made 48 hours before the current supply
of medication is exhausted.
d. If the patient has been determined capable of self-administration of their
medications (via physician's order), the patient then becomes solely responsible
for timely notification of pharmacy or nursing personnel regarding medication
needs.
G. Return to patient
a. The pharmacist, pharmacist’s designee or nurse may return the patient's stored
medications.
b. The pharmacist on duty at the time of patient discharge will ensure that stored
medication(s) are returned.
c. The pharmacist on duty is responsible to reconcile the stored medications with the
discharge medication list to determine clinical appropriateness and safety of
returning the stored medications to the patient.
d. The pharmacist shall consult the provider regarding any concerns for the patient’s
safety if the stored medications are returned to the patient.
i. If it is determined by the pharmacist and provider that it is unsafe for the
patient to go home with a stored medication, the provider or pharmacist
will notify the patient or patient’s representative that the medication will
be destroyed.
1. The provider shall write an order or give a verbal order authorizing
the pharmacist to destroy the medications.
2. Medications to be destroyed must be specified by name in the
order.
3. The pharmacist receiving an order to destroy medications will
obtain the stored medications, properly dispose of any medications
(refer to section H below), and document the following in the
patient's electronic medical record:
a. Who gave consent to destroy (patient or provider)
b. Which medications were destroyed
c. How the medications were destroyed
d. The pharmacist’s name destroying the medications

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 5
of 11

Title: Patient’s Own Medication Storage and
Use

e. The pharmacist should relabel stored medications if directions at discharge differ
from those at admission and ensure original dispensing pharmacy is not covered
up (see policy 7.80??)
f. During discharge consultation, the pharmacist will advise the patient regarding
the current status of stored medication(s) as related to therapy at the time of
discharge.
g. The pharmacist must document that the stored medications were returned in the
Patient Education activity comment filed in the Electronic Health Record.
h. In the event a patient is discharged and the stored medications are not returned,
the pharmacist or their designee will contact the patient regarding the disposition
of stored medications. Arrangements should be made for the patient or patient’s
representative to pick-up the medication, have the medications mailed/delivered,
or destroyed.
i. The pharmacist will document the conversation with the patient and the
decision made regarding the return of the stored medications in the
patient’s electronic medical record. This documentation will include the
name of the medications and how they were returned to the patient.
ii. If requested by the patient, the inpatient pharmacist will forward the
medications (along with the patient's name and address on the Stored
Medication Record) to outpatient pharmacy to be mailed to the patient.
iii. The inpatient pharmacist will notify the outpatient pharmacy if the
medication(s) are needed urgently and require overnight shipping;
otherwise the outpatient pharmacy will send via routine mail.
iv. The inpatient pharmacist will document the conversation with the patient
and the decision made regarding the return of the stored medications in the
patient’s electronic medical record. This documentation will include the
name of the medications and how they were returned to the patient.
H. Disposal
a. Pharmacist will discard patient's own medications if requested by the patient, if
the patient has expired, or if the patient’s provider orders such disposal.
b. The pharmacist will indicate in the patient’s chart within the electronic medical
record that the stored medications were destroyed.
c. If controlled substances are destroyed, the pharmacist will also complete a
controlled substance discrepancy from (UWH#9039). If the drug is a scheduled II
controlled substance then two licensed professionals must sign on "Action Taken"
line for drug wasted otherwise a single signature in this line is acceptable. After
the form is completed it is turned into the vault for filing.

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 6
of 11

Title: Patient’s Own Medication Storage and
Use

d. The pharmacist will follow disposal requirements outlined in Pharmacy
Administrative policies 1.43, Storage Handling, Security and Disposition of
Medications, and 1.31 Handling and Disposal of Hazardous Drugs in Pharmacy
Areas.
I. Lost/Contaminated Medications
a. Investigation
i. Lost/Contaminated medications
1. Upon notification of a missing patient’s own medication, the
decentral pharmacist must make an attempt to locate the
medication.
2. If the missing medication is not located, or if the medication was
contaminated, the covering pharmacist must investigate the
circumstances surrounding its disappearance or contamination for
documentation purposes.
b. Notification and Documentation
i. Once the investigation has been finalized, the covering pharmacist must
contact their manager and inform them of the loss. The manager on-call
should be contacted should this occur during non-business hours.
ii. The pharmacy manager will assess the need for the involvement of Patient
Relations and will give the authorization to fill the medication.
iii. Once authorized, the decentral pharmacist must then complete the “UW
Hospital Patient’s Own Medication Replacement Request Form” (see
Appendix B).
iv. The covering pharmacist will notify the patient of the situation and any
anticipated delays of care. If discharging, they should be informed of their
options to pick up their replaced medication(s) at the Outpatient
Pharmacy, or have them mailed to their home. If the patient requests home
delivery, the covering pharmacist will verify the mailing address with the
patient and transcribe it into the specified filed or attach it to the UW
Hospital Patient’s Own Medication Replacement Form.
c. Medication Replacement
i. Ordering and Filling
1. Decentral Procedure
a. The decentral pharmacist will generate a written
prescriptions for the lost medication(s) either through
Health Link or by hand. The pharmacist should utilize the
pharmacist management of electronic medication orders

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 7
of 11

Title: Patient’s Own Medication Storage and
Use

delegation protocol to generate new prescription(s) or
obtain legal prescriptions from a prescriber. The quantity to
be dispensed should be equivalent to the quantity of
medication which was lost.
b. Once the prescription has been generated, the covering
pharmacists will send the prescription and the UW Hospital
Patient’s Own Medication Replacement Request Form to
the Outpatient Pharmacy.
2. Ambulatory Procedure
a. Upon receiving a prescription with a UW Hospital Patient’s
Own Medication Replacement Request Form attached, the
technician must verify that all fields have been completed
and notify the inpatient pharmacist if additional
information is needed or missing from the form.
b. The prescription will be processed based on the timeline
indicated on the replacement request form.
c. Upon data entry, the prescription(s) will be scanned into
the system and the replacement request form must be
scanned into Enterprise in the Medical Authorizations
section located under the Privacy Management tab.
d. For billing, the technician will enter “PAT REL-UWHC”
under the insurance plan and must enter a transaction note
indicating that the prescription is a patient’s own
medication replacement along with the delivery option
indicated on the UW Hospital Patient’s Own Medication
Replacement Request Form.
e. When the medication is verified, the pharmacist will
confirm that a $0 copay is listed with the patient relations
bill code, and inform the technician that the medication is
ready.
ii. Dispensing
1. Upon notification by the verifying pharmacist, the technician will
complete the appropriate dispensing process based on the patient’s
status as indicated on the UW Hospital Patient’s Own Medication
Replacement Request Form.
a. Patient On the Unit:

POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 8
of 11

Title: Patient’s Own Medication Storage and
Use

i. Upon notification by the verifying pharmacist, the
technician must ring out the medication(s) and if the
patient is present, have them sign the signature box
when prompted. If the patient is not present, the
signature prompt should be bypassed.
ii. The technician will then send the medication to the
location indicated on the “UW Hospital Patient’s
Own Medication Replacement Request Form”, and
must page the covering pharmacist on the unit to
notify them of the transfer.
iii. The covering pharmacist will notify the patient of
receipt, and properly store the medication as
outlined in Section III.D.
b. Patient Discharging (Pick-up):
i. Upon notification by the verifying pharmacist the
technician must write “patient’s own medication
replacement” on the front of the medication
information sheet next to the barcode.
ii. The technician must check if the patient has any
other medications to be dispensed and will
consolidate them.
iii. Upon check-out, the patient will be notified by the
pharmacy personnel completing the point of sale
which medications were replaced.
c. Patient Discharging (Home Delivery):
i. Upon notification by the verifying pharmacist, the
technician will ring out the medication(s) and will
write “delivery” into the signature box when
prompted.
ii. After completion of the transaction, the technician
will follow the proper procedure to mail the
medication to the patient paying close attention to
the urgency indicated by the decentral pharmacist.



POLICY & PROCEDURE





Effective Date:

December 1, 2009
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual


Policy #: 3.5

 Original
Revision 12/16

Page 9
of 11

Title: Patient’s Own Medication Storage and
Use

IV: REFERENCES
A. Pharmacy Administrative Policy 1.43, Storage Handling, Security and Disposition of
Medications
B. Pharmacy Administrative Policy 1.31 Handling and Disposal of Hazardous Drugs in
Pharmacy Areas.
C. Hospital Patient Care Policy 8.17 Administration of Medications

V: COORDINATION
A. AUTHORED BY: Michelle Thoma, PharmD; Dave Hager, PharmD, BCPS; Joseph
Cesarz, PharmD, MS
B. REVIEWED BY: Dave Hager, PharmD, BCPS; Joseph Cesarz, PharmD, MS; and Philip
Trapskin, PharmD, BCPS
C. COMMITTEE APPROVAL BY: Inpatient Pharmacy Manager Committee



Approved By:___________________________
Director of Pharmacy Services

Date:_________________





















Appendix A
UW Health Stored Medication Form












































Appendix B



UW Health Patient’s Own Medication Replacement Request Form

View Replacement of Lost/Contaminated Patient’s Own Medication Operating Procedure for
instructions on how to complete this form. Tube to Outpatient Pharmacy #725

Patient Name: _____________________________________ Unit: ___________
Covering RPh: ____________________________________ Pager#: __________
Pharmacy Manager Authorizer: ________________________________________
Patient Relations Authorizer: __________________________________________
Prescription Billing: “PAT REL-UWHC”__________________________

#___ Medication(s) to be Replaced:____________________________________
_________________________________________________________________

Reason for Replacement (please circle):

Lost Contaminated Other: _____________________________

Investigation Summary:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Priority (please circle):

High (20-30 min) Med (30 min-1 hr) Low (>1hr): ________

Delivery Options (please circle):

Tube to Unit: #______ Patient Pick-up Mail-out (Overnight Yes / No)






Document Filling: Please scan this document into the patient’s Enterprise profile
Address (record below or attach):