Department of Pharmacy Policies & Procedures
Number: 4:11
Effective Date: August 2006
Revisions: 9/09
Approval: 08/2006
Subject: Narcotic Vault Downtime Procedure
A. POLICY
The purpose of this policy is to ensure the proper documentation and accountability of the removal/addition of controlled substances from the Pyxis CII Safe during periods of downtime.
NOTIFICATION OF DOWNTIME
As soon as a problem is noted with the CII Safe, the pharmacist-in-charge (“A” pharmacist) shall call the Pyxis World Wide Service Center at 1-800-727-6102 in order to report the issue and obtain technical support. The pharmacist should send an email to management noting the following information: their name, the date and time, and any comments from the Service Center technical support about the issue and its potential resolution.
MANUAL OPERATIONS
If the Pyxis CII Safe malfunctions, the procedure is to unlock panels at the top of the cabinet and pop open doors using the vault keys. The instructions for obtaining the vault keys during downtime are detailed below:
Mon-Fri days – The Pharmacy Assistant Director will maintain a set of keys to the vault. In addition to the Assistant Director, the Pharmacy Supervisor and the Pyxis Technician will know how to obtain the keys. (The round keys are needed for locks across the top of the vault) The keys must be returned to the individual they were obtained from after the vault has been opened.
Nights & Weekends – A pharmacy employee will take their employee ID badge to the UAMS Control Center and sign out the vault keys. An employee of the UAMS Control Center will call the pharmacy to verify that the pharmacy employee is authorized to pick up the keys. Take the keys to the pharmacy and unlock the vault, then return the keys to Control. (The Control Center is located behind the Clinical Laboratory on the 1st floor; go to the hallway near the lab and follow the signs to Central Control.)
Proper documentation must be maintained for all products removed or returned to the vault. If medications are taken to the automated dispensing machine (ADM)on a unit in response to a stock-out printed at the console, the pharmacy employee must sign that they replaced ‘x’ quantity at what time. If the ADM prints when drugs are loaded or refilled, the pharmacy employee can attach the printout to the stock-out form. If replacing stock in the IV Room, the pharmacy employee can attach a note to the full sign-out sheet stating their name, the time and date, and the quantity removed from the vault; use a new sheet of paper for each sign-out. If removing a medication for a single-dose to tube, the pharmacy employee can use the pink copy of the narcotic form as the necessary documentation. If filling an outpatient prescription for a narcotic, the pharmacy employee can put a copy of the prescription into the box; making sure that the employee has signed and dated both the original and the copy. All documentation should be placed in a box on the counter in the vault room.
The Refill – Delivery report that is generated from the Pyxis console printer at 10AM can be used for documentation by adding the pharmacy employee’s name, time, date, and amount refilled.
In the case of any other different circumstance which may occur not covered by
the above, a single-dose shingle sheet should be used for documentation of the
transaction. Please include the following documentation:
a. Date and time
b. Item
c. Quantity
d. Type of transaction
e. Automated dispensing machine (ADM)
f. Nursing unit and Patient name, if not to the ADM
g. Final inventory count
h. Signature of pharmacist
i. Signature of person who received
For future reference, a copy of this procedure is located in the vault room inside the front cover of the C-II Safe Management Guide binder. A location guide is provided to manually reference the locations of medications in CII Safe.
INFORMATION RECOVERY
Once the issue is resolved, a complete inventory of the CII Safe must be completed by a pharmacist (preferably the pharmacy supervisor and the Assistant Director for Medication Safety) and a technician (preferably the technician supervisor, the narcotic technician, or a QA technician). The “Medication Formulary Report” shall be printed from the CII Safe for reconciliation purposes. To print this report, go to CII Safe main menu, choose #20 “print medication formulary”, “by medication or location”, choose “L” for location. This will allow the CII Safe to be inventoried by compartment and the actual count can be reconciled with the computer’s count.
The following reports shall be obtained from the Pyxis Console once the inventory is completed:
(1) Refill report – This report shows all Medstation refill transactions by all users for a specified time, date and schedule class.
(2) Unload/load report – this report shows all medication transactions that were loads or unloads for a specific date, time and schedule class.
Once these reports have been obtained, the Assistant Director for Medication Safety will take these and other documentation from all the manual removals/additions from/to the CII Safe and match up each transaction. The Assistant Director will then reconcile the inventory by entering all transactions into the vault. After completing all transactions, another inventory will be completed by two pharmacists, or a pharmacist and a technician. Any discrepancies identified by this inventory will be investigated and resolved if possible.
Any discrepancy that cannot be resolved will be reported as a loss to the appropriate organizations based on Policy #6:07 Controlled Substances. The counts of those medications that cannot be reconciled will be manually adjusted by the Assistant Director for Medication Safety so that further inventories will be correct.
Any reasonable suspicion of diversion by any pharmacy employee may result in mandatory urine drug screens of these individuals. This situation will be handled according to the appropriate Human Resource policy.