MWE Controlled Substances

Implementation Date: 9/24/2009

Date of Last Revision: 12/11/2022

Next Review Due: 12/10/2025

 

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.

Policy

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

Guidelines

• 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 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, administration of controlled substances in the field should be witnessed by another clinician, staff member or client.
   
   
2. 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.
   
   
3. Controlled Substances: MWE Ambulatory Boxes
   Each MWE clinician will maintain their own ambulatory controlled substance box. This box must be kept locked at all times and stored attached to the assigned ambulatory vehicle with a cable lock when not in use. Each box must be brought to the VTH Medication Dispensary weekly for a pharmacist to check the contents. During that check, the pharmacist will verify that remaining quantity matches the log sheet and that charges were entered into the HIS for all logged drug removals.
   

   1. The MWE ambulatory boxes will contain the controlled substances needed for use by each MWE clinician when treating patients. Each box will contain the following:

   • Butorphanol (10ml): 3 vials
   • Euthanasia Solution (100 ml): 5 vials
   • Ketamine (10 ml): 3 vials
   • Midazolam (10 ml): 2 vials

   2. 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 boxes will be stored in the MWE ambulatory vehicles by securely attaching with a cable lock. Weekly, each clinician is responsible for bringing their box 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.
   
   3. When restocking the box, 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.
   When picking up the box, the clinician will sign the log sheet maintained in the pharmacy. The log sheet will have an entry each time the bag is verified by a pharmacist and then returned to the MWE clinician.
   
   

4. Medication Labeling
   Prescription label 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.
5. 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 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.
   
   
6. 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 box 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.