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Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Manufacturing and Repacking

Mngt. of Emergency and Non-Emergent Kits, Boxes, and Trays (8.7)

Mngt. of Emergency and Non-Emergent Kits, Boxes, and Trays (8.7) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Manufacturing and Repacking

8.7

POLICY & PROCEDURE





Effective Date:

September 2010
⌧Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 8.7

⌧ Original
…Revision
Page 1
of 5
Title: Management and oversight of
Emergency and non-emergent kits,
boxes and trays.


I. PUPOSE: To establish a uniform replenishment and bi-annual auditing procedure for
emergency and non-emergency kits, boxes and trays supplied by the Department of
Pharmacy to UWHC inpatient, clinic and procedure areas.

II. POLICY: The Department of Pharmacy will provide and maintain emergency and non-
emergency kits, boxes and trays containing medications for inpatient and clinic areas. This
policy covers emergency trays and boxes, emergency intubation kits, contrast reaction trays
and asthma/allergy boxes. Med Flight, Cardiac and Pediatric Transport Case Pack systems
are covered in Policy #15.6. The malignant hyperthermia box is covered under Policy #16.1.

III. FORMS:

A. Box, case pack, kit and tray accountability log – See appendix 8.7a
B. Checklist for Completing the Emergency and Non-emergency Kits, Boxes and Trays
Update - See appendix B (attached in policy)

IV. PROCEDURE:

A. Information on locations, contents and contact person for emergency and non-emergency
kits, boxes and trays will be maintained in the Stock List Database.
1. The Stock List Database is located on the J-drive: J:\Rx\RXShare\Clinics.
2. The Pharmacy Manager of Business Operations will be responsible for maintaining
this database as changes are made after communications from appropriate committees
listed in IV. B.

B. Changes to the contents and locations of emergency and non-emergency kits, boxes and
trays must be approved by the appropriate committee:
1. Resuscitation Review Committee must approve emergency tray and box changes.
2. All other box, tray and kit changes must be approved by Drug Product Selection and
Supply Committee (DPSS).

C. Restocking of emergency and non-emergency kits, boxes and trays will be completed by
central pharmacy staff.
1. Central Pharmacy should be contacted when an emergency and non-emergency kit,
box or trays is opened for use or potential use, or when the tray, box or kit is brought
directly to Central Pharmacy.

POLICY & PROCEDURE





Effective Date:

September 2010
⌧Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 8.7

⌧ Original
…Revision
Page 2
of 5
Title: Management and oversight of
Emergency and non-emergent kits,
boxes and trays.

a. Contrast reaction trays will be brought to Central Pharmacy by imaging staff, and
a replacement tray will be signed out and given to the imaging staff member.
b. An asthma/allergy nurse will page the clinics pharmacy technician at 8555 when a
replacement medication box is needed. A replacement medication box will be
signed out and delivered to nursing staff.
c. The AcuDose technician will bring used or opened intubation kits twice daily to
Central Pharmacy and will sign out and bring filled kits to the emergency room.
d. Emergency trays used in the CSC hospital or AFCH will be returned to central
pharmacy by decentral pharmacy staff or Central Services. A replacement tray
will be signed out and brought to the floor.
e. Emergency and non-emergency kits, boxes and trays used at off-site UWHC
clinics areas may contact the repackaging technician at (608)-263-1272, Monday
through Friday 0700-1530 to arrange for transportation of a replacement.
2. Kits, boxes and trays will be replenished by technical staff and verified by a
pharmacist before they are available for use.
3. The repackaging technician will refill all medications with medications that have
expiration dates beyond the expiration date on the outside of the tray, box, or kit.
They must replace all medications used, comparing contents against the list of
medications in the Stock List Database.
4. The central pharmacist will verify all medication in the tray, box, or kit before they
will be available for patient use.
5. All used trays, boxes, and kits received in the previous day must be restocked daily
by the end of the repackaging technician shift.
6. Repackaging technician and checking pharmacist should document on the “Box, case
pack, kit and tray accountability log” that each box, kit and tray was filled, entered
and dispensed.
7. The appropriate breakaway locks should be placed on each box and kit:
a. Emergency boxes: Yellow
b. Intubation Kits: Green
c. Asthma/Allergy boxes: Black
8. The number on each breakaway lock should be recorded on the box, case pack, kit
and tray accountability log
9. All emergency trays should receive tamper resistant breakaway wrapping in lieu of
breakaway locks

D. Pharmacy technician staff will ensure that the appropriate charging forms are completed
for each used medication box, tray or kit.

POLICY & PROCEDURE





Effective Date:

September 2010
⌧Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 8.7

⌧ Original
…Revision
Page 3
of 5
Title: Management and oversight of
Emergency and non-emergent kits,
boxes and trays.

1. The repackaging technician enters all used medications on the accompanying charge
form for each medication tray or box and places the completed form into the clinic
charges tray.
2. The pharmacy office staff picks the forms up daily and charges used medications to
the appropriate patient within the Healthlink system.
3. Charging forms for trays, boxes and kits can be generated using the Stock List
Database. A blank charging form should be placed into each kit, tray or box when it
is replenished.

E. Trays, boxes, and kits will be checked for expired medications on a biannual basis by
Central Pharmacy Staff in January and July of each year.
1. All trays, boxes, and kits updated in January shall contain medications that expire
after July 31
st
of the same year. Those updated in July shall contain medications that
expire after January 31
st
of the following year. Every effort will be made to adhere to
the expire date, however, the expire after date may vary due to drug shortages of
medications maintained within these boxes, trays or kits.
2. The central technical coordinator or designee will order additional supplies in the
month prior to updating floor stock trays, boxes, and kits to ensure adequate supply in
central pharmacy to replenish expired medications.
3. The “Checklist for completing the emergency and non-emergency tray, box and kit
update” outlines steps to be taken. Refer to appendix B below.

V. COORDINATION:
A. AUTHORED BY: Jack Temple, Dave Musa and Mary Demski
B. REVIEWED BY: Pharmacy Operations Committee
C. COMMITTEE APPROVAL BY: Pharmacy Operations Committee


Approved By: ____________________________
Director of Pharmacy Services

Date: ____________




Appendix A
BOX, CASE PACK, KIT AND TRAY
ACCOUNTABILITY LOG


Preparation/Restocking Phase
(Please complete these columns when prepping/restocking)
Issuing/Dispensing Phase
(Please complete these columns when issuing/dispensing)
Technician Filling
(initial and date)

Box/Tray/
Kit/Med
Flight
Pack #
filled
LOCK
NUMBER

RPH Checking
(initial and date)
Date/TIme
Dispensed
to
unit/location
Unit/Location
dispensed to
BOX/TRAY/Kit/Pack
# dispensed
SIGNATURE of PHA/RPH
dispensing
Example:
OU
1/8/07
1 123332 Bcl 1400
1/8/07
B6/5 #3 Brad Ludwig














Appendix B

CHECKLIST FOR COMPLETING THE EMERGENCY
AND NON-EMERGENCY KITS, BOXES AND TRAYS UPDATE


• Order drug one month in advance of the update.
• Print off the locations of all boxes, trays and kits from the Stock List Database found at
J:\Rx\RXShare\Clinics
• Gather supplies for the update: scissors, razor blades, blank labels, tape, and black markers.
• Make new expiration labels for boxes and trays. Highlight the expiration date in yellow.
• Check the dates on emergency drugs located in Repackaging. Remove all drugs that will expire
before the next update.
• As you receive drug with good expiration dates from the stockroom, arrange it alphabetically on a
cart. As soon as all the drugs are in you may begin the update.
• Update the trays first. Begin by updating all of the backup trays in Repackaging. Use these to
exchange all the trays on the floors. Check off the tray numbers as you update them.
• Update all the in-hospital boxes next. Begin by updating all the backup boxes in Repackaging. Use
these to exchange all the boxes on the floors.
• Update the outside clinic boxes last. These boxes will have to be labeled with the clinic address and
taken down to transportation to be exchanged. Some clinics you may need to call first to let them
know about the exchange. There are two locations that pick up their own boxes from Repackaging
(The McClain Center and the Mazomanie clinic). These two locations need to be called and told their
boxes are ready to be exchanged.
• After all the trays and boxes have been updated, restock the bins in Repackaging with the remaining
good drug. Excess good drug may be returned to the stockroom.
• Sort the expiring drugs for the stockroom. All drugs need to be sorted by the drug name, dose and
expiration date into separate bags. Any drugs that have expired or will expire in the next two months
should be considered “dead drug” and will not be included in the count of drugs being returned to the
stockroom. On the outside of each bag write the drug name, dose, expiration date, and the count. Fill
out a form with the number totals for each drug being returned to the stockroom. Separate bags of
expired drug from the drugs being returned to the stockroom and notify Karen Meier when you have
finished.
• Prepare a Box Tray and Kit Update report. Include total time needed to complete the update, total
cost per box and total cost per tray (use the most current formulary available), total cost for all the
boxes and trays, and total cost for all expiring drugs that were returned to the stockroom. See reports
from previous years as an example.
• File this report and all other information concerning this update in the emergency box and tray update
binder.

Updated 09/2010