Department of Pharmacy Policies & Procedures
Number: 5:08
Effective Date: June, 1996
Revisions: 2/02, 7/08
Reviewed: 9/09
Approval: June, 1996
Subject: USE OF AUTOMATED DISPENSING SYSTEM
POLICY:
Automated dispensing systems (ADMs) will be used in specified clinical care areas of the hospital in order to provide access to commonly used medications. Automated dispensing systems will be provided only in areas where there is sufficient need. All units will have drug access controlled by patient profile with the exception of areas where patients are transient and the physician is available including Emergency Department, Labor and Delivery, One Day Surgery, PACU and Jones Eye Pre-op.
PROCEDURE:
I. AUTHORIZED ACCESS
Access will be strictly maintained to insure adequate security for medication including controlled substances, provide for proper documentation of medication use, and to assure confidentiality of patient data.
A. Employees, nursing instructors, and nursing students** authorized to use the ADM will be assigned a username and password in order to be able to access any unit in the hospital. A Universal Confidentiality Agreement is signed by the employee during orientation to ensure that all codes and patient information are kept confidential. These codes will be entered into the console by the pharmacy department.
The UAMS Medical Center has determined that to ensure better user security users will be required to use the BioID fingerprint identification system. The ADM will prompt new user to scan their fingerprints upon their first login.
Some users may not be able to use their fingerprint due to the inability of the system to scan properly. This must be documented and maintained in the employee’s personnel file stating why they are unable to use their fingerprint and that they will be allowed to use a password.
**Nursing students cannot access any controlled substances for administration**
B. Employees will be assigned a temporary password by the Nurse Manager or ADON. Temporary codes require the user to choose a new password with the initial sign on. The temporary code is only valid for 12 hours from the time of issuance. The employee’s full last name, first name, and license classification (e.g., RN, LPN, etc.) is needed to add a temporary employee.
C. Physician/practitioner access is not authorized.
D. Employees who have forgotten their password must be reentered into the system following the steps outlined in A. A temporary user access may be assigned as outlined in B until another permanent access code can be used.
E. When an employee terminates or transfers permanently to a non-patient care area the pharmacy department is notified so that user privileges may be revoked.
F. Access Privileges for pharmacy and nursing are determined by their respective supervisors.
1. The following are different station access privileges:
A) Station login/witness ability - allows user to sign on to the system without medication access.
(B) Unscheduled medication access - allows user to remove, return, waste, and take inventory of non-controlled medications.
(C) Controlled substance medication access - allows user to remove, return, waste and take inventory of controlled medications. Wastes and inventories require a witness.
(D) Refill unscheduled medication - allows user to refill non-controlled medications in the ADM.
(E) Refill controlled substance medication - allows user to refill controlled medications in the ADM.
(F) Station system report access - allows user to access reports at the station.
(G) Station temporary user creation – allows user to create temporary users which allows them access for 12 hours.
(H) Load/Unload unscheduled medication - allows user to load/unload new non-controlled medication into the ADM.
(I) Load/Unload controlled substance medication - allows user to load/unload new controlled medications into the ADM.
2. The following are different pharmacy console access privileges
(AA) Basic pharmacy privileges.
(BB) Profile order access.
(CC) User creation privilege.
(DD) Pharmacy manager privilege.
3. General guidelines for assigning access privileges are as follows based on:
a. Pharmacy Technician - A,B,C,D,E,F,H,I,AA
b. Pharmacy Student - A,B,C,D,E,F,H,I,AA
c. Pharmacist - A,B,C,D,E,F,H,I,AA,BB,CC
d. Nursing Student - A,B,F
e. Nurse - A,B,C,F (includes nursing instructors)
f. Nurse Management - A,B,C,F,G
g. Pharmacy Systems Team - All privileges
II. MEDICATION ADMINISTRATION
See Nursing ADM Manual
III. ENTERING PATIENT INFORMATION
See Nursing ADM Manual
IV. OVERRIDE FUNCTION
A limited number of "emergency" medications are approved by the Pharmacy and Therapeutics Committee for which the override function will be available when pharmacy prospective review is not feasible. (See XIII below). Any additions must be approved by the P&T committee. Deletions may be made if misuse or nonuse of a drug are evident.
A. All override medications are not available on all units. Stock for each unit will be determined by the type of care standard to that unit.
B. The override function will be used only to access approved medications in situations in which their administration is deemed an emergency by the physician or where patient safety or clinical status would be compromised if delay for review incurred.
C. The nurse obtaining an override medication is responsible for ensuring that an order is generated/renewed for the drug.
D. The pharmacy will review override reports to check for improper utilization of drugs and if orders for the drugs have been submitted.
V. RETURNING MEDICATIONS
A. Any medication that is removed from the ADM that is in its original container (not opened) and will not be administered to a patient for whatever reason will be returned to the ADM.
B. The nurse returning a medication is responsible for returning the medication to the correct pocket, as guided by the system.
C. Only intact, reusable packages should be returned to stock. Any drug removed from a tamper resistant package must be placed in WASTE. Do not return it to stock. (See WASTING MEDICATIONS below)
VI. WASTING MEDICATIONS
A. If all or part of a controlled substance remains and cannot be returned to the ADM for future use, it must be wasted. Two nurses are required for wasting all controlled substances.
B. The documentation of the wastage should be completed at the time the controlled substance is wasted.
C. It is not necessary to document the wastage of a non-controlled substance on the ADM.
VII. CONTROLLED OR FLAGGED DRUG DISCREPANCY RESOLUTION
A. A discrepancy occurs when the physical count does not match the displayed count from the ADM. Discrepancies may be identified at any time when a nurse removes medication for a patient.
B. At the conclusion of each shift (at least one hour before the shift change), the charge nurse is responsible for printing a Discrepancy Report from the ADM.
C. Any discrepancies in count of the controlled substances must be resolved before the end of the shift. If a discrepancy cannot be resolved, the Head Nurse Manager or ADON must be notified.
D. All unresolved discrepancies must be documented by the HNM/ADON on a hospital variance report which includes names of all personnel accessing the system for the period of time in question.
E. At the conclusion of each shift (1 hour before shift change) the CDF will run an Activity Report on "All Users" for Class II and Class III, IV, and V drugs. These reports will be checked for non-shift employees, excessive dosing, double sign-outs on the same patient, and other unusual activities. A Discrepancy Check Log is provided by the pharmacy to each nursing unit for documentation (Appendix G).
VIII. INVENTORY COUNT
A. Controlled substances will be inventoried twice a week (every Monday and Thursday morning) at the morning shift change by nursing personnel. The inventory counts will be performed by two nurses - one to count the drugs and one to read the ADM screen.
B. Controlled substance counts will also be verified during each transaction.
C. Non-controlled medications will be inventoried by pharmacy personnel during loading and refilling and at other specified times.
D. At least once a month expiration dates will be checked by pharmacy personnel.
IX. OUT OF STOCK AND NON-STOCKED MEDICATIONS
A. Controlled Substances:
All controlled substances placed in the ADM require a witness. Pharmacy personnel will request that a nurse observe and verify that the correct amount is entered into the inventory and physically placed in the drawer.
Pharmacy department Day Shift - narcotic technicians manage all refills, stockouts, and loads in the ADM.
Evening and Night Shift Stockouts - central technicians will refill stockouts. The ADM transaction slip must be attached to the controlled substance signout log in the Central Pharmacy.
Evening Shift "Med Not Loaded" - new items will be loaded into the console by a pharmacist. Only single dose items such as epidurals or IVs will be handled manually.
B. Non-controlled Substances:
Pharmacy personnel will be responsible for replacing out of stock items.
Loading new items will be performed once a day. "Medication stock outs" will be handled on an individual basis.
Inventory levels will be checked daily. These medications will be delivered and refilled into the ADM by pharmacy personnel. The inventory count must remain accurate during this transaction.
Medications which run out before theoretical inventory does will be replaced by the pharmacy within the hour upon notification by a message request and/or phone call. If this is a continuing problem for a medication or a particular unit, the manager will be contacted. If the problem is not resolved, the medication will be flagged for perpetual inventory as a controlled substance with the necessity of resolving discrepancies.
Non-ADM items and first issue items for medication not in the ADM will be dispensed to the patient’s medication bin. Non-ADM items (i.e.; extemporaneously prepared items, non-standard doses, etc.) will be dispensed daily using the cartfill list.
Non-stocked non-controlled substances in the ED will be obtained from the pharmacy via a charge ticket.
Stock and inventory level changes stored in the ADM will be based on usage and patient convenience. Forms will be submitted from non-Profiled area managers/staff for these requests.
X. REPLACING TRANSACTION PAPER
Replacement rolls of paper should be stocked with other paper supplies and purchased from the stockroom.
XI. DOWNTIME PROCEDURE
A. The ADM should be connected to the hospital’s emergency power system with a UPS battery backup installed.
B. In the event the Pharmacy console is without power, the pharmacy must immediately contact the PYXIS Service Center for instructions on shut down procedures on the pharmacy console. The ADM units will automatically shut themselves down.
C. If it becomes necessary to manually open the ADM on the unit, the pharmacy must be contacted. The keys to open the ADM will be stored in the Narcotic Vault in the Central Pharmacy. If deemed necessary by the pharmacist and charge nurse, the ADM will be opened using the following guidelines based on the length of the power outage.
a. Non-controlled substances: The drawers will remain open and disposition and charging will be performed manually using the ADM manual charging form
b. Controlled substances: The drawers will be opened and the drugs currently being used will be transferred to a locked cabinet. Inventory will be transcribed on a separate ADM charging form. Any remaining controlled substances in the ADM will be relocked.
c. If there is a breakdown in communications between the console and the ADM for a sufficient length of time that the profiles will be outdated, the ADM will be placed on Critical Override. This allows open access to the ADM. PYXIS Customer Support and/or Pharmacy Administration must be notified to assist in resolution of the problem.
XII. PROBLEMS WITH THE SYSTEM
A. Use the following steps to help solve problems occurring with the ADM:
1. Consult PYXIS Reference Manual located on the unit
2. Direct the questions to the unit resource nurse of the pharmacy.
3. Contact PYXIS System Coordinator
4. Contact PYXIS Service Representative through pharmacy personnel
B. For guidelines for specific problems refer to Nursing PYXIS Manual.
XIII. REPORTS
A. Pick and Delivery - Controlled Substances: This report prints daily. It lists per nursing unit, controlled substances at or below par. The controlled substance technician(s) will use this report to restock controlled substances in the ADM.
B. Pick and Delivery - Non-controlled Substances: This report prints daily. It lists per nursing unit all non-controlled substances at or below par. The central pharmacy ADM technicians use this report to restock non-controlled substances in the ADM.
C. Returns and Wastes - Controlled Substances: This report prints daily, listing all returns and waste activities which have occurred. These reports will be used to verify medications removed from the returns bin.
D. Med Refill Activities Report: This report prints daily and lists all controlled substance refills. It is used by controlled substance personnel to assure all controlled substance refills were handled appropriately.
E. Non-accessed pockets: This report prints twice weekly (Mondays and Thursdays). It is used as a management tool for unloading pockets.
F. Loading and Unloading Report: This report prints daily. It lists per individual all loads and unloads of controlled substances. It is used by the controlled substance personnel to assure that the controlled substances were handled appropriately.
G. Medications Ordered and Not Loaded Report: This report prints once a day. A pharmacist reviews this report to determine which meds to load into ADM.
H. Discrepancy and Open Discrepancy Report: This report prints daily. It lists per nursing unit all controlled substance discrepancies. It is used by the controlled substance personnel to follow up discrepancies.
XIV. LIST OF OVERRIDE DRUGS AND RATIONALE