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UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Administrative

OR Controlled Substances - Holidays, Inpatient OR, AFCH OR and TAC (1.03)

OR Controlled Substances - Holidays, Inpatient OR, AFCH OR and TAC (1.03) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Administrative

1.03

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE




EFFECTIVE DATE

AUGUST 2008
ORIGINAL
 REVISION

MAY 2017
PAGE 1
OF 3
POLICY #

1.03
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OR CONTROLLED SUBSTANCES – PM, NIGHTS, WEEKENDS, PM, NOC, WEEKEND,
HOLIDAYS, INPATIENT/AFCH/TAC INTRAOPERATIVE AREAS




I. PURPOSE

Provide and account for controlled substances in the Operating Rooms during evenings (after 2230), weekends,
and holidays.

II. POLICY

A. Controlled substances will be obtained by licensed personnel only.
B. The individual who administers the controlled substance will be responsible for documenting the use
of those medications.
C. The main OR (Inpatient) Room is staffed from 0630-2230, Monday through Friday and 0630-1430 on
weekends and holidays by a Pharmacy Technician. ID badge reader permits access to Anesthesia
providers and OR nursing staff from 2200-0700, Monday through Friday and all day Saturday,
Sunday, and holidays. The door to the pharmacy-only side of the OR pharmacy to be kept closed at all
times unless OR pharmacy technician or pharmacist is present. The door that is accessible to non-
pharmacy staff will be open at all times (either physically or by scanning the name badge).
D. Controlled substances will be maintained in the Anesthesia Accudose cabinets in the OR suites at
The American Center.

III. PROCEDURE

A. Fill out the narcotic request form after patient evaluation.
1. This form is located inside the Inpatient Pharmacy (E7/391) and AFCH Pharmacy (3311) or
attached to the premade narcotic packets (see #3).
2. The top (white) copy stays in the Pharmacy and the bottom (yellow and pink) copies accompany
the narcotics.
3. Completion of form includes: patient name, medical record number, date, OR room number,
anesthesia staff and resident or RN if moderate sedation case.
B. Obtain the designated narcotics for the surgical procedure from the Pharmacy.
1. Ask the charge nurse to obtain the narcotics for you when the pharmacy technician is not
staffing.
C. Utilize the premade narcotic packets available in the narcotic drawers when applicable.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE




EFFECTIVE DATE

AUGUST 2008
ORIGINAL
 REVISION

MAY 2017
PAGE 2
OF 3
POLICY #

1.03
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OR CONTROLLED SUBSTANCES – PM, NIGHTS, WEEKENDS, PM, NOC, WEEKEND,
HOLIDAYS, INPATIENT/AFCH/TAC INTRAOPERATIVE AREAS


1. Premade narcotic packets for routine CV, thoracic/liver/trauma, vascular, or routine cases are
available to expedite dispensing the controlled substances.
D. Triage/charge nurse to obtain any additional controlled substances needed during the case by the
anesthesia provider from the additional night supplies drawer in the Pharmacy.
1. Remember to add additional controlled substances to white narcotic record that stays in the
Pharmacy. If there are cases still going when the pharmacy technician leaves for the day, he/she
will place the white narcotic record on the counter for the charge nurse to add additional
controlled substances if needed.
E. Record any additional controlled substances obtained during the procedure on the yellow and pink
copies of the request form.
F. At the completion of the procedure, return any unused and partially used controlled substances. Fill
in on the narcotic request form what drugs were administered, wasted, returned, and the signature of
the person returning the drugs. Return unused drugs and the pink copy to the narcotic drop off slot
labeled “returns” in the in Inpatient Pharmacy (E7/391) and outside of the AFCH Pharmacy (3311).
Return wasted drugs and the yellow copy to the narcotic waste box labeled “waste” in the Inpatient
OR Pharmacy (E7/391) and outside the AFCH OR Pharmacy (3311). .
1. Empty vials/syringes may be discarded in black pharmaceutical waste container during the
procedure.
2. Any contaminated syringes should be emptied and discarded in the OR. Use black
pharmaceutical waste containers for all pharmaceutical waste including chemotherapy and
investigational medications. Black containers are obtained through Environmental Services.
3. Assure all sharps/needles and tubing have been removed.
4. The anesthesia care provider is responsible for returning the medications.
5. In the event of inadvertent waste, all wasted narcotics must be witnessed by two licensed
personnel. Both individuals need to sign the narcotic request form.










UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE




EFFECTIVE DATE

AUGUST 2008
ORIGINAL
 REVISION

MAY 2017
PAGE 3
OF 3
POLICY #

1.03
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OR CONTROLLED SUBSTANCES – PM, NIGHTS, WEEKENDS, PM, NOC, WEEKEND,
HOLIDAYS, INPATIENT/AFCH/TAC INTRAOPERATIVE AREAS


REVIEWED BY

Surgical Services Policy and Procedure Committee 2/2017
Megan Donovan, Clinical Pharmacist 2/2017
Cathy Madsen, Director, Surgical Services AFCH, MSN, RN 2/2017
Tricia Ejzak, Nursing Education Specialist, TAC 4/2017

SIGNED BY

Anne Mork, MHCDS, MS, RN
Director, Surgical Services Department