Department of Pharmacy Policies & Procedures

Number: 5:17

Effective Date: October, 1987

Revisions: 5/95; 1/03; 2/04; 11/09

Reviewed:

Approval: 10/87

Subject: MEDICATION BROUGHT TO THE HOSPITAL OR OUTPATIENT CLINIC BY THE PATIENT

 

A. POLICY

Patients at the UAMS Medical Center shall receive their medications from the pharmacy of the hospital. Medication filled for the patient outside the UAMS Medical Center shall not be used for in-patient treatment.

Patients who have prescription and non-prescription drugs in their possession at the time of admission should be encouraged to give these drugs to a family member or trusted friend to take home with them. Every effort shall be made to have the drugs removed from the hospital by reliable means. An exception to this policy is if the attending physician has asked the patient to bring the drug to the hospital for identification and drug history.

Patients who are visiting UAMS Outpatient Clinics shall not be allowed to bring in medications from home for clinic preparation or administration.  An exception to this policy is if the Pharmacy Director or designee has been contacted, extenuating circumstances have been explained, and this has been approved by the Pharmacy Director or designee.

B. Procedure for Proper Storage

1. In the event it is not possible to send the medication home, the nursing staff will explain the policy of not using the home supply and will remove the medication from the patient's possession for storage.

2. The medication will be placed in a bag and taken to the inpatient pharmacy.

3. A "Pharmacy Drug Receipt Form" is completed by the pharmacy staff. The receipt consists of the original (white) and two copies (yellow and pink). The white is kept in the central hospital pharmacy; the yellow is placed into the patient's chart and the pink is given to the patient.

4. The bag of medications with the white copy of the form attached is stored in the pharmacy area designated for this purpose.

5. As the medications are received they are to be logged into the Home Medication notebook located in the main pharmacy. Entries should be legible!

6. When the patient is discharged, the personnel on the nursing unit are to request that the medications be sent to the unit. During the discharge counseling procedure, the medications are returned to the patient with appropriate instructions. When such medication are returned, entry is made into the Home Medication Notebook.

7. Once a month the pharmacy will check the patient’s disposition and if they have been discharged, mail the medication to the patient's home via certified, registered mail.

8.. Medication of patients who expired while hospitalized will not be mailed. These medications will be disposed of in an appropriate manner.

C. Handling of Controlled Substances brought in by the Patient

1.      Controlled substances (CII - C IV) will be removed from the patient's supply and stored in a designated compartment of the CII Safe. If there is adequate room in the controlled bag, all meds may be stored in the Cll Safe.

 

2.      The drugs will be placed in a "Security Bag". These bags are stored in the CII Safe under "Security".

 

3.      Remove a bag from the CII Safe.

 

4.      Write the date and patient's name on the blank side of the bag.

 

5.      Write the number of containers to be placed in the bag, the drug name, and the quantity of the controlled substances.  Controlled substances must be counted by a pharmacist.

 

6.      Two signatures must also be on the bag to verify the contents, one must be the pharmacist who counted the substances.

 

7.      Remove the numbered receipt from the bag and attach it to the patient receipt form on the bag of non-controlled drugs which are being stored. If there are only controlled substances, or if all meds have fit into the Security Bag, place the paper receipt and the Security Bag Receipt together on the outside of the Security Bag.

 

8.      Seal the bag. Be sure everything is in the bag before sealing as the bag must be destroyed to be reopened.

 

9.      Place the bag in designated compartment of the CII Safe per policy.

D. Mailing Medication to the Patient's Home

1. At the time the patient meds are mailed home the date they are mailed will be logged into the Home Medication notebook in the appropriate place. If they are controlled substances they will be sent by certified mail. This will be noted in the Home Medication notebook.

2.  If Home Meds are returned to the Pharmacy after being mailed out they will be either disposed of once a quarter or if they are controlled substances delivered to the Health Department. If they are disposed of, they will be highlighted in the Home Medication Notebook. A Pharmacy Tech will then dispose of medications with a Pharmacist as a witness. The Pharmacist will initial that they have witnessed the medications being disposed. Controlled Substances are logged into another record and noted as sent to the Health Department in the Home Med notebook.

3. The white copy of the "Pharmacy Drug Receipt" is kept for a period of three months in the Pharmacy Control Lab. After three months, the receipts are destroyed.

4. All medications mailed home will be accompanied with a letter of explanation to the patient.

E. Using Medications Brought to the Hospital

1. Should the attending physician prescribe a non-formulary drug which is available from the patient's drug supply, the following procedure will be followed.

a. The policies governing the ordering and use of Non-Formulary Drugs do apply.

b. A pharmacist will examine the patient's medications and attempt to make a positive identification of the drug requested.  The drug will be visually inspected for crumbling, discoloration and other signs of deterioration.

c. If identification is accomplished and the integrity of the drug is verified by inspection, the drug is dispensed to the patient in the Unit-Dose system. This will be used for "first doses" or for all doses if the hospitalization is very short. Otherwise a supply of the drug will be obtained for dispensing to the patient.

d. In the event that a positive identification cannot be made, or if the drug is not in a useable condition, the patient's nurse and prescribing physician will be informed.

2. Formulary drugs will not be dispensed from the patient's supply. However, on limited dose drugs such as oral antibiotics, oral contraceptives, etc, professional discretion is allowed.

3. IV medication brought to the University Hospital prepared by a third party company NOT associated with the UAMS Medical Center will not be allowed to be used by the patient in the hospital. Exception may be made for certain investigational or limited access drugs at the discretion of the pharmacy director or designee.

4. Should the patient bring IVs prepared by an affiliated third party (i.e. ACC or ACRC pharmacies), the patient will be allowed to use the quantity remaining from the last fill of the prescription upon comparison and verification against the current medication orders. Once that quantity is expired, the patient will begin to receive IV medication from the hospital pharmacy according to hospital procedures.