MWE Controlled Substances

VTH Policy #MWE1

Implementation Date: 9/24/2009

Date of Last Revision: 4/6/2023

Next Review Due: 4/5/2026


Reviewed by VTH Administrative Team: 9/8/2009

Reviewed by VTH Board: 9/24/2009


Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.


Midwest Equine (MWE) must follow guidelines for the transport, usage, storage and wasting of controlled drugs within their veterinary practice. 


  • Documentation around controlled substances must be consistent, whether it is related to ordering, inventory storage, administration and/or disposal. This includes witnessing administration. 
  • Wasting of controlled substances will be documented and wasted in RxDestroyer. 

Procedure (if applicable)

  1. Controlled Substance Documentation
    Documentation around the use of controlled substances will be consistent whether related to ordering, inventory, or administration. The chain of custody for any controlled substance will be readily tracked through the ordering to administration or wastage time sequence.

    Clinicians will secure a witness when administering controlled substances in the clinic. Whenever feasible, the administration of controlled substances in the field should be witnessed by another clinician, staff member or client.

  1. Controlled Substance Inventory
    Controlled substances will be inventoried weekly. Inventory activity is defined as checking balance of medication in storage versus amount of medication that is to be "on hand" based upon documented use. The veterinarian(s) and MWE Director should be advised re: any discrepancy between amount of medication "on hand" and anticipated volume of medication based upon documentation. The Director or DVM will consult with the college pharmacists re: documentation and reporting requirements related to the drug discrepancy. The VTH Hospital Director shall be notified when the matter has been identified and addressed. It is the Hospital Director’s responsibility to notify the Dean as an informational item.

  2. Controlled Substances: MWE Ambulatory Bags
    Each MWE clinician will maintain their own ambulatory controlled substance bag. This bag must be kept locked at all times and stored attached to the assigned ambulatory vehicle with a cable lock when not in use. Each bag must be brought to the VTH Medication Dispensary weekly for a pharmacist to check the contents. During that check, the pharmacist will verify that the remaining quantity matches the log sheet and that charges were entered into the HIS for all logged drug removals. 

      1. The MWE ambulatory bags will contain the controlled substances needed for use by each MWE clinician when treating patients. Each bag will contain the following:
      • Butorphanol (10ml): 3 vials
      • Euthanasia Solution (100 ml): 5 vials
      • Ketamine (10 ml): 3 vials
      • Midazolam (10 ml): 2 vials

      1. Each drug will have a tamper-proof bag. Each vial will have a yellow log sheet attached to it. Each time the drug is used, it must be logged on the yellow sheet. When a vial is emptied, the empty vial and yellow sheet shall be returned to the Dispensary.

      The bags will be stored in the LAC Cubex when not needed for calls. Weekly, each clinician is responsible for bringing their bag to the Dispensary to have the quantities and logs verified by a pharmacist. The pharmacist will do an actual draw for all opened vials in open tamper-proof bags. The pharmacist will mark the verification on the yellow log sheet and restock the kit as necessary. The pharmacist will also verify that the charges were entered for each dose logged on a yellow sheet.


      • One bag is indicated for intern use. This bag will be issued to the intern currently assigned to the MWE service and will remain secured in the Cubex machine until they’re assigned on-call duty. At the conclusion of the assignment, the bag will be returned directly to the dispensary for a pharmacist to verify each item. The verification will be completed prior to issuance to the next intern.

      1. When restocking the bag, the pharmacist will enter a ward stock charge for the necessary medication and pin the medication through. A yellow log sheet will be filled out in the standard manner.
        After verification and restocking is complete, dispensary staff will return the bag to the LAC Cubex for the clinician to remove when needed.

      2. When not on call, the assigned ambulatory bag must be stored in the LAC Cubex overnight. Each doctor will have their own Cubex login and a Cubex code for removing and returning their assigned bag to allow tracking. 


    1. Medication Labeling
      Prescription labels compliant with the Illinois Veterinary Practice Act will be affixed to any medication dispensed to a client. At a minimum, the label will contain the following information:
      o         Date on which the medication is dispensed
      o         Name of the client
      o         Last name of the person dispensing the medication (i.e., the prescribing doctor)
      o         Directions for use including dosage and quantity
      o         Proprietary or generic name of the drug.

    2. Controlled Substance wasting and waste auditing
      Controlled substances that have been prepared for a patient but are no longer needed must be wasted in accordance with applicable Federal and state regulations. This includes a waste log documenting the drug name, quantity, initials of both the person destroying the controlled substance and initials of a witness and date wasted. Drug must be discarded via the RxDestroyer (which allows for destruction of both solid and liquid waste). Once RxDestroyer system is full, it must be disposed of properly by DRS (Division of Research Safety) and replaced with a new one.  

    3. Controlled Substance Training
      All faculty and staff that may be asked to handle controlled substances must be trained on controlled substances policies and procedures, which may include a course document, VTH Controlled Substance Policies and Procedures. If applicable, each person will need to review the document and “sign” that they have read and understood the requirements by checking the bag to indicate so. In addition, all faculty, staff, and students must review and sign a document indicating that they agree to follow controlled substance policies.  

    Definitions (if applicable)

    Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.

    KeywordsMWE, Midwest, Equine, transport, usage, use, store, storage, waste, disposal, wasting, controlled , drug, substance, administration, RXDestroyer, document, inventory, director, discrepancy, ambulatory, box, pharmacist, pharmacy, vehicle cable lock, yellow, log sheet   Doc ID124267
    OwnerJenny C.GroupUofI College of Veterinary Medicine Teaching Hospital
    Created2023-02-22 15:34 CDTUpdated2023-05-01 11:07 CDT
    SitesUniversity of Illinois College of Veterinary Medicine Teaching Hospital
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