After Hours Controlled Drug Dispensing

VTH Policy # Pharmacy631

Implementation Date: 10/2021

Date of Last Review: 3/22/2023

Next Review Due: 3/21/2025


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.


The intent of this policy is to provide a method for dispensing controlled substances to patients being discharged while the dispensary is closed. This policy covers controlled substances that are being dispensed to a patient leaving the hospital while the dispensary is closed. This policy does not apply to controlled substances being obtained for in-patient use or non-controlled medications. When the VTH Dispensary is closed, and a patient is being discharged that needs continued treatment with a controlled substance, a 72-hour supply may be dispensed by a clinician from the emergency dispensing cabinet located in the VTH dispensary. If medication treatment is needed beyond 72 hours, a prescription must be filled by dispensary staff during normal hours or sent to an outside pharmacy.


  • Dispensing of an emergency supply of a controlled substance may only be done by a VTH clinician with prescribing authority. 
  • A quantity closest to what will provide 72 hours of therapy should be selected. Any additional medication must be processed as a normal prescription during dispensary hours or sent to an outside pharmacy. 
  • A prescription must be entered through VetStar and pinned off by the clinician on both the doctor side and the pharmacy side. 
  • A label must be placed on each medication container. If more than one pre-packaged container is needed, then the clinician must print a duplicate label for each container. 
  • The clinician obtaining the medication is required to sign the hardcopy prescription that prints, as well as document cabinet access and medications removed in the logbook by placing a patient label in the logbook.
Medications contained in the cabinet include:
Buprenorphine 0.3mg/mL solution for oral use  (1 mL increments)  Midazolam Intra-nasal seizure Kit
Codeine 30 mg tablets (individually packaged)  Phenobarbital 15 mg tablets (individually packaged)
Diazepam 5 mg tablets (individually packaged)  Phenobarbital 60 mg tablets (individually packaged)
Hydrocodone 1 mg/ml Syrup (Packaged 5ml bottles) Tramadol 50 mg tablets (individually packaged)
Hydrocodone/Homatropine Tablets 5 mg/1.5mg (individually packaged) Tylenol w/ Codeine #3 (individually packaged)

Procedure (if applicable)

  1. A prescription is entered into the HIS for the medication needed. 
  2. The prescribing clinician pins off on the prescription on both the doctor worklist and the pharmacy worklist. This will trigger 2 labels. 
  3. The clinician removes the key from the ICU Cubex under the patient that the medication is being prescribed for. To find the key, search under “After Hours controls key”. 
  4. The clinician enters the dispensary using badge access and removes the prescribed medication from the lockbox cabinet using the key.
  5. The prescribed quantity is removed from the cabinet and placed into a standard pill vial or amber bottle.
  6. One label is placed on the medication bottle and one label is placed on the cabinet logbook. The clinician must sign and date the log sheet. It is expected that the clinician pinning off the prescription is the clinician obtaining the medication from the pharmacy. 
  7. Make sure the cabinet is locked when done, and return the key to the Cubex under the same patient for which it was removed. Use the return function on Cubex for this

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.



KeywordsPharmacy, medication, dispensary, controlled substance, dispense, dispensing, after hours, closed, discharged, supply, prescription, lockbox, key, phenobarbital, buprenorphine, seizure, hydrocodone, cabinet, Cubex, supply, 72 hour   Doc ID126821
OwnerJenny C.GroupUofI College of Veterinary Medicine Teaching Hospital
Created2023-03-22 14:56 CSTUpdated2023-03-22 15:06 CST
SitesUniversity of Illinois College of Veterinary Medicine Teaching Hospital
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