Ward Stock & Research Controlled Drugs

Implementation Date: 10/2021

Date of Last Revision: 3/21/2023

Next Review Due: 3/20/2025

 

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

The purpose of this policy is to explain the process for ordering Controlled Drugs that will be used for research or as ward stock.This applies to all Controlled Substance drugs entered into the HIS or paper request for a Ward Stock or Research account. Drugs will be requested by either paper request (Ward Stock Request Form) and signed by a DVM, or entered into the HIS and pinned off by a DVM. The VTH Department or Research Department agrees to take the necessary precautions and safety in handling Controlled Substances. Only researchers with a clinical appointment with the VTH will be permitted to obtain controlled substances for research through the Medication Dispensary.

Guidelines

Drugs will be filled with a 10% price markup fee, within an appropriate time frame by Dispensary staff with necessary proper documentation and will need to be dated and initialed by the individual picking up drug. 

Procedure (if applicable)

1. Controlled substances needed will be written on the ward stock orders provided by dispensary via email or hardcopy or electronically entered into the HIS and pinned by the authorizing DVM. Paper orders must have a signature on them from the requesting veterinarian next to the controlled substance. The pinning/signing DVM is responsible for ensuring the security of the drug and that all requirements below are adhered to.
   
   
2. Dispensary staff will fill the controlled substance in the HIS under the VTH Department or Research Account. Once it is entered with sufficient doctor approval, it needs to be pinned by the pharmacist. Department/ Researcher will give Pharmacy sufficient time for drug to be filled. 
   
   
3. Dispensary staff will fill the drug. If drug needs to be ordered, dispensary staff will notify the recipient with approximate time frame. 
   
   
4. If multi-dose vial of controlled substance, dispensary will fill out a Yellow Sheet documented with Drug name & Strength, Department, Quantity, Date Filled, Date of Drug Expiration, RX # and DVM the prescription is under. Dispensary will keep top sheet of carbon copy for record keeping until Yellow Sheet is returned along with leftover or empty drug vial. Documentation of the Yellow Sheet Record # will be documented on drug packaging. 
   
   
5. Department or Research Account will document each time the multi-dose vial is used with MR #, if applicable, along with mg or ml used and quantity remaining along with date and initials, and witness. 
   
   
6. When not in-use, controlled drugs must be stored in a Medication Dispensary-approved location or returned to the dispensary for storage until needed again.
   
   
7. When yellow sheet and empty vial are returned, the vial # must match the Yellow Sheet Record #, and documented quantity remaining must match actual quantity remaining (with exception of HUB loss use). Dispensary staff will cross out remaining lines on Yellow Sheet and document amount remaining/ discarded, date returned and initial. 
   
   
8. Dispensary will compile a list of all outstanding ward stock and research controls quarterly and contact approving DVM for verification of the status of those medications

Definitions (if applicable)

HIS: Health Information System

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.