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Medication Floor/Area Stock (13.13)

Medication Floor/Area Stock (13.13) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Drug Policy

13.13

POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 1
of 6
Title: Medication Floor/Area Stock

I. PURPOSE: To establish uniform guidelines for a drug product to become floor/area
stock

II. POLICY: The following procedure will be used in requesting a drug to become
floor/area stock for inpatient units or patient care areas such as the procedure rooms,
operating rooms, clinics, and emergency room. The Drug Product Selection and
Supply Committee (DPSS) is responsible for approving all stocked medications and
their locations at UWHC before they are stocked.

III. FORMS: UWHC Medication Floor/Area Stock Request – found on U-Connect

IV. DEFINITIONS:
a. Emergency Drug Boxes and Trays contain medications for use in emergency
resuscitative events. The Resuscitation Committee and DPSS will determine
which medications will be stored in emergency drug boxes and trays. Duplication
between floorstock and drugs located in emergency drug boxes and trays should
be minimized.
b. Inpatient Floorstock consists of as needed (PRN) medications and controlled
substances. Whenever feasible, floorstock will be contained in AcuDose cabinets
or in refrigerators as medication storage requirements dictate. Items may be
maintained outside of AcuDose cabinets and refrigerators if appropriate, but these
items should be kept to a minimum.
c. Pharmacist Stock/Substation stock consists of medications needed on an urgent
basis that cannot be maintained as floorstock due to size or need for compounding
prior to administration. These medications are locked and only accessible to
pharmacists. These medications should only be utilized when the first dose
distribution system would negatively impact the patient’s clinical outcome.
d. Operating Room and Procedure Area Stock consists of medications needed for
treatment of patients during surgical and procedural cases.
i. These medications are used according to established procedures under the
direct control and supervision of a physician in the peri-operative or
procedural setting.
e. Ambulatory Clinic Stock consists of medications used in the treatment of
patients in the ambulatory clinics.
i. These medications are used according to established procedures by order
of and under the general supervision of a physician.




POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 2
of 6
Title: Medication Floor/Area Stock

V. PROCEDURE
a. Initiating the floorstock request
i. Clinical staff will contact a pharmacist on their respective inpatient units,
the operating room pharmacist, or their liaison pharmacist in their
respective outpatient/ambulatory care areas to initiate a request for a drug
product to be added to floorstock. Pharmacists can also initiate the
request. All requests are consider only for the specific area unless
specified on the request form.
b. Evaluating the floorstock request
i. The following considerations should be used when evaluating the
floorstock request:
1. Utilization
a. How often is the medication used in that specific area?
b. Is the medication part of a protocol, orderset, etc.?
c. Is the medication part of a procedure done in clinic?
2. Patient Safety Concerns
a. Are there other medications stocked in the area that could
lead to medication errors: multiple concentrations of the
same medication, similar sounding names or appearances,
high alert medications?
b. Are there complicated calculations required to prepare
and/or administer the correct dose of the medication?
3. Emergent Use
a. Is the medication considered a STAT item that is not
stocked in the crash cart/emergency trays/ emergency
boxes?
b. Is there clinical harm or cost implication to the patient if
the medication is received through the current drug
distribution system?
c. Are there patient satisfaction issues that classify the
medication as emergent?
4. Hospital Policy Considerations
a. Policy 13.20: Safety Strategies for Handling Sound-alike
and Look-alike Medications
b. Policy 8.33: High Alert Medication Administration
c. Policy 8.89: Preventing Occupational Exposure to
Hazardous Drugs
d. Policy 1.24: Storage, Handling, Security, and Disposition
of Medications

POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 3
of 6
Title: Medication Floor/Area Stock

e. Policy 8.30: Management of Clinic Administered
Medications with Internal Pharmacy Prior Authorization
5. Preparation/Storage Requirements
a. How is the medication prepared?
b. Does the medication need to be manipulated before
administration?
c. What is the expiration date of the medication?
d. Is the medication a controlled substance?
e. Does the medication have special storage requirements
(protect from light, refrigerate, etc.)?
f. Is there physical space for the stocking of this new
medication in the area?
6. Drug Shortage
a. Is the medication on the drug shortage list?
b. Has the medication had frequent issues with shortages?
7. Reimbursement
a. What is the cost of the medication?
b. Are there concerns with getting reimbursed from payers?
c. How will the medication be billed and to whom?
8. Removal of floorstock items
a. Will the stocking of this medication allow for removal of
another medication?
b. What other medications can be removed to allow for more
space in the area?
c. Completing the floorstock request form
i. If the request is consistent with section (b) above, the requestor will enter
the request using the online UWHC Medication Floor/Area Stock Request
Form
ii. Fully completed request forms will be reviewed by the DPSS Committee
d. The chair of the DPSS Committee will discuss any issues pertaining to the
completion of the request form with the requester.
i. Request forms may be sent back to the requestor for more information
before the request is taken to the DPSS committee
e. Process for floorstock request review and approval
i. The floorstock request will be presented to the DPSS Committee.
ii. The requester may be invited to attend the committee meeting for further
clarification of the request
iii. The committee will vote to approve or deny the request
f. Communicating floorstock changes

POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 4
of 6
Title: Medication Floor/Area Stock

i. DPSS Committee meeting minutes will outline decisions on floorstock
additions and deletions and the floorstock database will help to coordinate
operational changes needed based on the decision of the request
ii. The requester will be notified of the results via e-mail by the chair of the
DPSS Committee or an assigned designee
iii. If the requester would like to appeal the decision upon denial, he/she may
do so by resubmitting the floorstock form identifying only new pertinent
information from the original request
iv. Requests previously denied by the DPSS committee may be reconsidered
at a later date
1. The reconsideration is outside of the appeal process
2. The reconsideration must be 6 months past the original denial
3. A request form must be submitted at this later date
g. Stocking of antibiotics
i. All requests for stocking antibiotics must be reviewed by the
Antimicrobial Subcommittee prior to the DPSS committee decision
h. Reviewing floorstock lists
i. All approved medication floor/area stock lists must be reviewed annually
by the DPSS Committee for appropriateness and potential for deletions
ii. The criteria used to evaluate the original request will be used during the
annual review (see section (b) above)
iii. The list of medications along with any suggestions for deletions will be
forwarded to the DPSS Committee for action through completion of a
floorstock request form
i. Medication floor/area stock will be resupplied by pharmacy personnel
i. Only items approved for stock by the DPSS Committee will be stocked
ii. Pharmacy staff will inspect stock locations for outdated medications and
compliance with regulatory standards (see policy 1.19: Regulatory
Compliance Inspections for more details)
iii. Any unapproved stock found in an area will be removed by restocking
technician
iv. There may be some areas that, by exception, pharmacy may delegate the
routine stocking and expiration date checking to non-pharmacy personnel
but that in all such cases, the Pharmacy Department is responsible for
developing the restocking and expiration date checking procedures and
will monitor performance of these systems to ensure compliance with
these procedures

POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 5
of 6
Title: Medication Floor/Area Stock

j. Medication floor/area stock in the American Family Children’s Hospital Pediatric
Day Treatment clinic will be maintained by pharmacy and clinic nursing
personnel
i. Patient specific controlled substances for use in the Pediatric Sedation
Program will be obtained from the AcuDose-Rx automated dispensing
cabinet immediately prior to each case.
1. All controlled substance dispense, return and waste activity from
the automated dispensing cabinet must follow Policy 14.4
AcuDose-Rx
2. All controlled substances must be returned or wasted within the
automated dispensing cabinet between each patient case. The
storage of controlled substances in a non-automated location for
use in future cases is not permitted.
ii. Non-controlled medications for use in the Pediatric Sedation Program may
be stored in the Pediatric Day Treatment Clinic secure medication room in
pediatric sedation kits as permitted by this policy.
1. Only medications approved by the DPSS Committee may be
inventoried in pediatric sedation kits.
2. Nursing personnel may resupply non-controlled inventory for
pediatric sedation kits from the AcuDose-Rx automated dispensing
cabinet
3. Pediatric sedation kit inventory replenishment must be dispensed
under the individual patient for whom it was used.
iii. All medication administration must follow the procedure as outlined in
Administrative Policy 8.56 Pediatric Sedation Policy
k. A database of all approved floorstock items and quantities per inventory location
will be maintained by pharmacy

VI. REFERENCES AND RELATED POLICIES, PROCEDURES
a. Policy 13.20: Safety Strategies for Handling Sound-alike and Look-alike
Medications
b. Policy 8.33: High Alert Medication Administration
c. Policy 8.89: Preventing Occupational Exposure to Hazardous Drugs
d. Policy 1.24: Storage, Handling, Security, and Disposition of Medications
e. Policy 8.30: Management of Clinic Administered Medications with Internal
Pharmacy Prior Authorization
f. Policy 1.19: Regulatory Compliance Inspections
g. Policy 14.4 AcuDose-Rx
h. Policy 8.56 Pediatric Sedation Policy

POLICY & PROCEDURE





Effective Date:

November 2002
⌧ Pharmacy Policy Manual
Chapter: Drug Policy
Operations Procedure Manual
Chapter:

Policy #: 13.13

Original
⌧ Revision
October 2013
Page 6
of 6
Title: Medication Floor/Area Stock


VII. COORDINATION:
a. AUTHORED BY: Kimberly Sherman and Clinic non-stocked medication
workflow steering committee
b. REVIEWED BY: DPSS Committee
c. COMMITTEE APPROVAL BY: P&T Committee


Approved By: ____________________________
Director of Pharmacy Services

Date: ________________