Controlled Substances Policy

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 expectations regarding controlled substance handling in the VTH. This applies to all people using controlled substances within the VTH, VMSC, WMC, and Midwest Equine and all associated services.

All controlled substances must be maintained in a secured manner with legally compliant record-keeping that indicates the disposition of all controlled substances from the time they are ordered until they are administered to the patient, wasted, or dispensed. Violation of this policy is subject to disciplinary procedures which may include termination of employment.

Guidelines

• All controlled substance administration must be documented and signed by a witness
• Controlled substances may only be obtained as single doses immediately prior to administration. Pre-drawn syringes obtained from Cubex are considered single use.
• Controlled substance waste must be logged in Cubex if possible or returned promptly to the Medication Dispensary for appropriate wasting if logging the waste in Cubex is not possible. After logging waste in Cubex, the drug must be wasted immediately by putting the drug into an RxDestroyer (VMSC and Dispensary) or placing the waste in a locked drop box (all other Cubex machine locations).
• No controlled substances may be retained or acquired for use other than for appropriate VTH patient care.
• Controlled substance prescriptions and orders shall be issued only for legitimate medical purposes in VTH patients.
• No controlled substance access should be provided to unauthorized individuals
• The required quantity countback must be completed to the best of the employee’s ability when removing a controlled substance from the Cubex machine.
• Controlled substances are not to be transferred from anesthesia to ICU. Any remaining drug after anesthesia must be wasted appropriately.
• All ward stock controlled substances must be securely maintained in an approved storage location including responding promptly to pharmacist questions on logs and quantities. All expired ward stock must be returned to the dispensary for documentation and disposal on or before the expiration date. All ambulatory bag controlled substances will be maintained in accordance with dispensary policies.
• Notify the pharmacist on duty immediately of any discrepancies or concerns related to controlled substance usage

Procedure (if applicable)

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.