Controlled Substance Waste Auditing

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

This applies to all controlled substances for patient use. Intended for completing spot checks of records to ensure that controlled substance waste is being accurately documented and that it corresponds to the medical record.

Random audits of controlled substances will be conducted quarterly and any discrepancies and compliance issues will be submitted to the Hospital Director. 

Guidelines

All areas of the VTH are subject to this random audit. Discrepancies and compliance issues found under this process will be submitted to the Hospital Director.

Procedure (if applicable)

1. The VTH Pharmacist(s) will conduct a random audit of controlled substances quarterly against patient medical records. All areas of the Veterinary Teaching Hospital are subject to this check.
   

   a. Records must include:

   i. Identify of patient
   ii. Dose administered or dose-by-dose administration
   iii. Person administering the drug
   iv. Verification and documentation of any wasted drug including partial doses

   b. Medical records will be verified against prescription records and/or Cubex records.

2.  Random reconciliations will include one CII and one CIII-V amount for four different patients.
   

   a. Each patient will be in the hospital on different dates. An effort will be made to pull patients under the care of different departments.
   b. Patients will be randomly selected by looking at waste logs and/or Cubex records. Ideally, one patient will be selected from Cubex records in each of the following locations (Anesthesia, LAC, ICU/ER and VMSC).
   c. Of the medications that a patient has received, one CII medication and one CIII-V medication will be selected for auditing. 
   d. The audit will include the following:

   i. Reviewing the RX history screen in SANDI to determine each time the drug was obtained (Cubex or Dispensary).
   ii. Reviewing treatment documentation (purple sheets and/or ICU treatment sheet) to verify that each dose administered was signed off and that the amount indicated as given in the record matches the amount ordered on the treatment sheet (if applicable).
   iii. If the dose that was obtained was different than the dose administered, review the waste log to verify that the appropriate amount of waste was logged.

3. Discrepancies and compliance issues found under this process will be submitted to the Hospital Director.

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.