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UWHC,

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

OR Controlled Substances - Weekdays, Inpatient OR, AFCH, TAC and OSC (1.04)

OR Controlled Substances - Weekdays, Inpatient OR, AFCH, TAC and OSC (1.04) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Administrative

1.04

UNIVERSITY OF WISCONSIN

POLICY &
PROCEDURE
EFFECTIVE DATE

November 1984
ORIGINAL
 REVISION

MAY 2017
PAGE 1
OF 2
POLICY #

1.04
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OR CONTROLLED SUBSTANCES - WEEKDAYS,
ALL INTRAOPERATIVE AREAS




I. PURPOSE

Provide and account for controlled substances in the Operating Room, Monday through Friday 0630-2230.

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. Refer to UWHC Policy #5.27 - Waste Management.
D. Main OR Pharmacy (E7/391) is physically staffed from 0630-2230 Monday through Friday by a
pharmacy technician and 0630-1430 on weekends and holidays.. AFCH OR Pharmacy (3311) is
physically staffed from 0630-1730 Monday through Friday and via phone Monday through Friday
from 1730-2230 and on weekends and holidays. OSC OR Pharmacy (F6/206) is physically staffed
Monday through Friday from 0630-1730 and via phone from 1730-2230 Monday through Friday.
This area is closed on holidays and the weekends. ID badge reader permits access to the non-
pharmacy side in the Main OR pharmacy for Anesthesia providers and OR nursing staff from 220-
0700Monday through Friday and all day Saturday, Sunday, and holidays. ID badge reader permits
access to the non-pharmacy side of the OSC OR Pharmacy and AFCH OR Pharmacy at all times.
The door is to be kept closed at all times unless the OR pharmacy technician or pharmacist is
present.

III. PROCEDURE

A. Fill out the narcotic request form after patient evaluation and leave with the pharmacy technician in
the Pharmaceutical Room, E7/391 and OSC Room F6/206 and AFCH Room 3311. If the pharmacy
technician is not present, the slips can be left by the technician’s work area.
1. For patients on the printed OR schedule, these forms are bar code labeled with the patient’s
name, filed in folders by OR room number and left in the rack in the OR pharmacies..
2. –The anesthesia provider must fill out their own narcotic forms for add on cases. This
information includes: patient name, medical record number, date, OR number, anesthesiologist’s
name (if applicable), and person’s name obtaining medications.
B. Pick up filled orders from the pharmacy technician.
1. The pharmacy technician will be stationed in the OR no later than 0630 for controlled substances
to be picked up.
2. The top (white) copy stays with the pharmacy technician and the bottom (yellow and pink) copies
accompany the narcotics.

UNIVERSITY OF WISCONSIN

POLICY &
PROCEDURE
EFFECTIVE DATE

November 1984
ORIGINAL
 REVISION

MAY 2017
PAGE 2
OF 2
POLICY #

1.04
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OR CONTROLLED SUBSTANCES - WEEKDAYS,
ALL INTRAOPERATIVE AREAS


C. Obtain any additional controlled substances needed during the case from the pharmacy technician
and verify what was ordered is what is received.
D. Record any additional controlled substances obtained during the procedure on the yellow and pink
copies of the narcotic request form.
E. 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 pink copy to the narcotic drop slot
“Returns” in rooms E7/391 and F6/206 and outside of AFCH room 3311. Return wasted drugs and
yellow copy to the narcotic waste bin “Waste” in rooms E7/391 and F6/206 and outside AFCH room
3311.
1. Empty vials and syringes may be discarded in black pharmaceutical waste containers during the
procedure.
2. Any contaminated syringes should be emptied and discarded in the OR. Use black
pharmaceutical waste containers for all pharmaceutical waste (without sharps) including
chemotherapy and investigational medications. Black pharmaceutical waste containers are
obtained through Environmental Services.
3. The anesthesia care provider is responsible for returning the drugs.
4. Assure all sharps/needles and tubing have been removed.
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.
6. Any remaining medications left in vials must be drawn up into syringes before returning to the
waste slot. Do not return needles with syringes. These should be discarded in a sharps container.
F. Obtain controlled substances for subsequent surgical procedures at this time.

IV. 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