Handling of controlled substances Veterinary Teaching Hospital

The purpose of this SOP is to establish appropriate procedures for the procurement, distribution, use, record-keeping, and disposal of controlled substances within the anesthesia service of the veterinary teaching hospital.

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1. Procurement of controlled substances: 

  1. Log into Cubex using fingerprint or login information
  2. Correctly enter patient name into Cubex patient screen
  3. Select appropriate supervising faculty member on clinics
  4. Select controlled substance and confirm correct concentration
  5. Enter in milliliters (mls) the amount of controlled substance needed
  6. Once Cubex drawer opens, confirm controlled substance is correct and do a countback PRIOR to drawing up drug
  7. Once countback has been completed, use alcohol swab to disinfect vial top and draw amount entered in Cubex with an appropriately labeled syringe
  8. After confirming the correct amount was drawn, return controlled substance vial to appropriate Cubex compartment and close the drawer
  9. Once all controlled substances have been drawn, EXIT out of Cubex

2. Distribution and use of controlled substances

  1. The individual that entered the controlled substance into the Cubex is responsible for the drug until it is appropriately returned to the Medication Dispensary to be discarded.
    1. The location, use, storage, and disposal of the controlled substance must always be known by the individual who obtained it.
  2. It is NOT permitted to transfer controlled substances between services

3. Record keeping of controlled substances

  1. Once a controlled substance is administered to a patient, the following information MUST be recorded on the patient record
    1. Name of controlled drug administered
    2. Dose in milligrams (mgs)
    3. Route of administration
    4. Time of administration
    5. Initials of person administrating
    6. Initials of witness to administration
  2. Unused controlled substances must be recorded in Discarded Drugs section of patient’s anesthetic record  
    1. Name of controlled substance
    2. Amount in milligrams (mgs) discarded
    3. Initials of person discarding the drug
    4. Initials of witness to discard

4. Disposal of controlled substances

  1. Place patient label on the vial or syringe of controlled drug to be discarded
  2. Confirm that drug was documented on patient record under discarded drugs
  3. Log the controlled drug waste in the Cubex, ensuring the waste is registered under the correct patient
  4. The individual responsible for the controlled substance must deposit the labeled drug in the grey wall-mounted lock box for proper disposal by Medical Dispensary personnel.

5. Missing and/or misuse of controlled substances

  1. Any missing vials, syringes, or amounts of controlled substances need to be reported immediately, or at least within 24 hours to the pharmacist on duty
  2. Any misuse or suspicions of abuse should be reported immediately to pharmacist on duty

Keywords:controlled, drugs, cubex, medication, discard, throw out, anesthesia   Doc ID:123585
Owner:Tina O.Group:University of Illinois College of Veterinary Medicine Teaching Hospital
Created:2023-01-26 14:48 CDTUpdated:2023-01-31 12:18 CDT
Sites:University of Illinois College of Veterinary Medicine Teaching Hospital
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