1. POLICY

All controlled substance handled by the UAMS Pharmacy Service will be stored in the PYXIS C-II Safe. All procedures for operation of the C-II Safe are in the manuals provided and will not be covered in this policy.

TERMINOLOGY:

Station – An automated dispensing unit located in a patient care area. – Pyxis 2000 or Pyxis Medstation

Compartment – Each door or section is called a compartment

Pocket – a labeled section within the compartment which holds a particular drug

Patients – each Pyxis Automated Medication Station and/or patient care are using controlled substances will be listed as a "patient"

User – Each employee authorized to enter the C-II Safe is designated as a user

1. Orientation to the use of the C-II Safe must be satisfactorily passed before personnel may have access to it.
2. Daily a report on discrepancies in the C-II Safe is generated. This report is given to the pharmacist manager for resolution.
3. Daily a "Pyxis vs C-II Safe compare" report is printed and reconciled by the narcotics technician. Any discrepancies are called to the attention of the pharmacy manager. This report is filed.
4. The delivery sheet printed by the C-II Safe when items are removed must be signed by a nurse when the items are delivered.
5. The signed delivery sheet is matched with the Pyxis Delivery receipts and kept for 1 month.
6. The Daily Activity Log is printed each morning for all activity in the C-II Safe for the previous day. This log is filed as a permanent file.

1. Each day the narcotic technician will run "Automatic Pyxis Restock" (#5) on the Main Menu. The information on the screen will be reviewed and adjusted if needed for usage or insufficient inventory.
2. When corrected, the Pharmacy Pick List Review will be accepted and printed.
3. The appropriate doors will automatically open and total quantities needed of drugs will be removed under direction of the C-II Safe sofeware.
4. As drugs are picked, the final inventory after the removal of the drug must be entered.
5. Drugs will be separated and placed in delivery bags by location.
6. The Delivery list will be attached to the medications.
7. A pharmacist will check the medications against the Delivery list and sign the list.
8. For locations without a Pyxis, the Controlled Drug Administration Records, drug supply, and the delivery sheet must all match. The pharmacist will sign the CDAR and the Delivery Sheet.
9. Receipts from the narcotic delivery will be matched with the Delivery Report for correct medication and quantity entered as well as all drugs delivered.

1. If a non-formulary controlled drug must be obtained for a patient it must be added to compartment #20 of the C-II Safe-NV. This is performed through the "Alter Medication Database"function (#17 on the Main Menu) . Check a print-out of compartment 20 to discover empty pockets.
2. If the drug is not in the Pyxis Medstation Inventory it must also be added to this inventory. For the Medication ID, use the pocket number - ie. – N20A indicated compartment 20 pocket A.
3. All non-formulary drugs must be loaded into the C-II Safe Narc Vault.

1. Any drug UNLOADED from a nursing PYXIS must be returned to the C-II Safe Narc Vault. The unloaded drug may not be taken to another unit and loaded.
2. The drug is returned using #12 "Return Without a Reference #" immediately after it is unloaded from the nursing unit PYXIS.
3. Controlled Drugs removed using the EXPIRED DRUGS on an inventory check will not be refilled back into the Narc-Vault stock but will be placed in the "Pending Destruction" bin (compartment 28) using #20 option 2 on the Main Menu.

1. If the physical inventory in the C-II Safe-NV does not match the theoretical inventory a discrepancy is created and a Discrepancy Report prints on the printer.
2. The person who discovers the discrepancy shall first re-inventory the drug (#20, Option 1 on the Main Menu) Surrounding bins should be checked for misplacement of the drug. If the second count agrees with the theoretical count, the discrepancy will be corrected simply by the inventory function.
3. If the second count does not agree with the theoretical count or the reason for the discrepancy is known, the person discovering the discrepancy shall write the reason for the discrepancy on the Discrepancy Report and give it to the narcotic technician..
4. The pharmacy manager must resolve the discrepancy using the Management Menu.
5. In order to determine the reason for the discrepancy if may be necessary to run a "Narc Vault Access Report" or other reports from the Reports menu.

1. Dispense unit-dose syringes in a sealed container. Do not take loose, unsecured syringes to the nursing units or return them to dispensing stock in the Narc Vault.
2. If the name of the medication has "Bulk", enter the total number removed as ml. or mg as appropriate to the drug.

Stations Using CDARs

                When a CDAR is returned to the pharmacy from a nursing unit, the CDAR barcode must be de-allocated by using Main Menu #10 - "Return with a Reference Number" before it is replaced and filed.