Controlled Substance Count-back

Implementation Date: 10/2021

Date of Last Revision: 3/6/2023

Next Review Due: 5/2023

 

Reviewed by VTH Administrative Team: 10/2021

Reviewed by VTH Board: N/A

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

To document the process for completing the controlled substance count-back when removing drugs from Cubex. All individuals removing a controlled substance from a Cubex machine is required to complete the Controlled Substance Count-back.

Guidelines

Dispensary staff will review, investigate and resolve discrepancies. If large quantities or repeated discrepancies indicate a concern for diversion, security camera footage will be reviewed.

Procedure (if applicable)

1. When a controlled substance is selected to be accessed in a Cubex machine, a verification of the quantity on hand will be required.
2. The person removing the medication should determine how much medication is in the bin PRIOR TO removing their dose. 
3. Verify if the actual quantity matches the quantity that Cubex indicates should be in the drawer. 
   a. If the quantity matches, tap the ‘next’ button on the screen to move on to removing your dose.
   b. If the quantity does not match, enter the actual quantity found and tap the ‘next’ button. The Cubex will then tell you the count is different and ask you to verify your adjustment. If your adjustment is what you intended, then tap the ‘next’ button again to move on to removing your dose.
4. If you adjust the quantity a substantial amount (i.e. more than a ml of liquid or at all for individual dosage units), send an email to vthpharmacy@vetmed.illinois.edu to alert Dispensary staff that there is a potential issue. If you notice a vial is leaking or have another idea why the discrepancy may have occurred, include that information in your email. 

Resolving Discrepancies

1. Once a discrepancy is created at a cabinet by the above process, it will show up in myQLink and require resolution. 
2. Daily (M-F) a pharmacist will review all discrepancies and resolve them by indicating a reason for the discrepancy and entering their password. Discrepancy review includes counting sticks to determine hub loss (0.05ml/stick), reviewing transactions for potential problems and reaching out to people that have accessed the bin since the last quantity verification. If large quantities are missing indicating a concern for diversion, security camera footage can be reviewed.

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.