Department of Pharmacy Policies & Procedures

Number:    5:01.4

Effective Date:     5/90

Revisions:   11/97; 5/02; 10/09

Approval: 7/02

Subject: SURGERY SATELLITE OPERATIONS

A. PURPOSE

The OR Satellite Pharmacy is established to provide improved control over patient charges and narcotic records, to provide improved accessibility of medications and drug information to the Surgery staff, and to improve communications between surgery, anesthesiology, nursing and pharmacy.

B. POLICY

The OR Satellite Pharmacy will be open 12.5 hours daily Monday – Thursday and 10 hours on Friday and will service the Surgery Suites, Anesthesiology, the PACU and the Pre-Op Holding Area.  The satellite will conform to all policies of the pharmacy as well as to unique policies which appear in the appendix of this document.

C. PROCEDURE

1.  Services Provided by the OR Satellite Pharmacy

a) Dispense medication used in surgical procedures, in pre-operative preparation of the patient or in immediate post-operative care of the patient.

b)  Maintain drug trays for the Anesthesiology Procedure Carts.

c)  Supervise record-keeping of controlled drugs dispensed and used in the OR.

d)  Provide random sampling of opened controlled drugs returned by anesthesiology at the end of a case.

e)  Provide drug information in response to specific requests.

2.  Duties of the OR Pharmacist

a) Assume responsibility for maintaining appropriate inventory, security and accountability for all medications stored in the OR satellite.

b)  Assume responsibility for proper storage, dispensing and record-keeping of controlled substances maintained in the OR satellite.

c)  Dispense medication used in surgical procedures.

d)  Maintain drug trays for Anesthesiology.

e)  Provide drug information in response to specific requests.

f)   Prepare intravenous fluids for surgical procedures.

g)  Prepare irrigating solutions used in surgery.

h)  Provide and maintain a supply of medications in a night cart for use during hours in which the OR Satellite Pharmacy is not open.

i)   Prepare epidural solutions ordered by the Anesthesiology Pain Team and provide pain management pumps for use with epidural solutions.  Maintain a record of pumps dispensed.

3.  Procedures for Operation

a) The OR satellite is open from 6:30 A.M. until 7:00 P.M. Monday – Thursday and 6:30 A.M. until 4:30 P.M. on Friday.  It is closed on holidays and weekends.

b) The pharmacist and technician working in the OR satellite will wear scrubs.  However, OR-laundered scrubs are not required.

c) Each morning, the OR pharmacist will issue thiopental syringes to the 5E anesthesiology residents.

d) The OR pharmacist will place a stocked drug tray in the anesthesia cart in each OR suite according to the posted schedule.  When trays are placed, all cart drawers are closed and the cart is locked with a red plastic lock.  The anesthesiologist will re-lock the cart between cases.

e) Any cardiac drips ordered are made the evening before and delivered to the Heart Room each weekday morning.

f) A narcotic tally sheet is started for the day and narcotic returns from the night or weekend are reconciled.

g) Controlled substances are checked out on a case-by-case basis during the day.  The anesthesiologist will also request refill items for the medication tray when picking up controlled drugs.

h)  A controlled drug requisition and a general stock list are prepared each morning.  The narcotic technician from the central pharmacy will pick up the narcotic request.  The technician will pick up non-controlled stock from the pharmacy stockroom each day.

i) In the morning, as time allows, the OR pharmacist will reconcile the narcotic record for the previous 24 hours.

j)  Charges from the anesthesia records are generated and filed for charging by a pharmacist or technician the same day.

k)  Stock is delivered in the afternoon and put up.

l) Six “regular” trays and three "neuro" trays are prepared for use after satellite hours.  On weekends, prepare six trays and one "neuro" tray.  These trays are placed in the anesthesia workroom Monday through Friday prior to the OR satellite closing.

m) Fresh supplies of phenylephrine and nitroglycerin solutions are prepared before closing.  These are labeled, flagged on the I.V. tubing at the stopcock, and hung in the anesthesia work room.

n) Narcotics are inventoried at closing.

o) A cart is available after hours for items not on anesthesia trays or for items needed by nurses. This cart has a key lock and is accessible only by OR nursing staff.

p) After-hours controlled substances are available from the automated supply station, which is accessible only to OR nursing staff.

q) The controlled drug supply and the pharmacy door are both locked whenever the pharmacist is absent from the room.

APPENDIX OF POLICIES UNIQUE TO PRACTICE IN THE OR SATELLITE PHARMACY

1.  Dispensing Drugs in the OR Satellite Pharmacy

a)  Accountability for drugs used in the OR will be achieved by dispensing on a case-by-case basis to the individual patient.  Unused drugs are to be returned to the pharmacy and will be credited if previously charged to the patient.

b)  Any medication needed for patients in the OR will be obtained from the OR satellite and charged on the following forms.

i)   Pre-op Holding Order sheet – for pre-operative antibiotics and any other medications needed prior to surgery.

ii) Medication Order Sheet – for items requested by OR nursing staff.  The same sheet is used during the work day and after hours.

iii) Controlled Substances Requisitions - For anesthesiologists and/or nurse anesthetists to request all controlled substances during the day and after hours. 

iv) Anesthesia Record – for drugs administered peri-operatively.

c) Drugs used from the night cart and the “eye” cart will be replaced by charge to a patient. 

2.  Anesthesia Trays

a)  A standardized drug tray will be furnished to each anesthesia cart daily.  In addition, 8 trays will be provided to the One Day Surgery area daily for use in JEI and ODS.  These ODS trays will be sent Monday, Wednesday, and Friday between 3-5pm by an anesthesia technician from the 2E OR.

b) After each case the anesthesia tray items will be replaced by anesthesiologist request.  If drugs not available on the tray are required, they are requested on a case-by-case basis and will be used or returned for credit after each case.     

c) Whenever practical, medications will be supplied in unit-of-use containers.  All vials will be replaced after any partial use and will not be carried from case to case.

d)  Charges for anesthesia cart trays are made only from the pharmacy copy of the anesthesia record for the individual case.  These records are also available as an adjunct for accountability of controlled drugs.

e)  On completion of the last scheduled case of the day, used trays are returned to the OR Satellite Pharmacy.  If the pharmacy is closed, the trays are returned to a designated area in the anesthesia workroom.  Used trays in ODS will be returned to the tray cart with the locked cover in place.

f)   All refrigerated items placed on the anesthesia trays will be monitored to reveal their duration of use at room temperature by using dated labeling.  Items will be discarded if the allowable time to be stored at room temperature has been exceeded.  Expiration dating will be as follows:

Cisatracurium Inj., 21 days

Famotidine Inj., 6 months

Pancuronium Inj., 60 days

Rocuronium Inj., 60 days

Succinylcholine Inj., 60 days

g)  All trays will be inspected weekly to insure that the entire contents are in-date, in good condition and properly labeled.

h)  After hours, a supply of anesthesia trays will be kept in the anesthesia workroom.  On weekends and holidays, the workroom is checked in the morning and the afternoon by pharmacists from the central pharmacy for any used trays that need replacement.  

3. General Medication Orders

a) Medications required for patient use while in the OR may be obtained from the OR Satellite Pharmacy with a Medication Order Form (MOF) supplied by pharmacy.  This form is located either at the satellite or on the night cart.  Medications are supplied on a case-by-case basis.

b)  The MOF will be filled out by the pharmacist with the patient's name, account number, and the OR room location.  Additional drugs may be obtained during surgery by adding to this form.

c) Unused drugs must be returned to the OR satellite at the end of each case and they will be removed from the MOF.  No drugs charged to the patient may be retained in the OR by the staff for use on another patient.

4.  Dispensing Controlled Substances

a)  Controlled substances are dispensed to licensed health care professionals only from the Anesthesia and Nursing departments upon receipt of a properly completed requisition.  These drugs are dispensed on a case-by-case basis to maximize control of usage and wastage.

i)  A controlled substance may only be transferred when the full legal signature of the recipient is on the "Controlled Substance Record" form.  The recipient then assumes complete and non-transferable responsibility for the disposition and return of the form and any unused drug.  The pharmacy retains the top copy of the form for tracking.

ii)  The completed form and any unused drug must be returned to the pharmacy before the recipient may obtain drugs for future cases.  Any unreturned form must be found by the recipient and reconciled by the pharmacist.

iii)  Information from the completed form is recorded on the "Controlled Substance Usage Record" in the pharmacy so that inventory can be reconciled with usage.

b)  Any wastage of controlled substances must be done by the recipient (person administering the drug).  This must be witnessed by one other licensed person (M.D., R.N., or pharmacist) and documented on the form.  Both persons must be present at the time of wasting.  The term "wasting" shall mean that all liquid or solid contents are directed into a sewer drain.  Only the container empty of all contents may be discarded into solid waste containers.

c)  As part of quality control and anti-diversion procedure, partial syringes from at least 2 procedures daily will be kept and forwarded to the pharmacy quality control laboratory for assay rather than wasted.  Any unusual findings shall be reported to the Chairman of Anesthesiology.

5.  Night Cart

a) The night cart is used as a source of non-narcotic medications during the hours when the OR Satellite Pharmacy is closed.  The inventory levels are set to provide an adequate amount of medications for evening and night use as well as on weekends.

b)  The night cart is located in the hallway outside the OR Satellite Pharmacy.

c)  The cart is locked at all times and keys are kept by head nurses on each shift.

d)  Charge tickets are kept on top of the cart and completed whenever a drug is removed.

e) Medications not on the cart may be obtained from the central pharmacy.

6.  Resuscitation Drugs for Anesthesia

Several drug items used by anesthesia for resuscitation are prepared in syringes daily on a contingency basis.  These drugs will be replaced to the tray whenever used.  All syringes prepared for the day will be labeled and dated.  These syringes are discarded after 24 hours.