PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process
OBJECTIVES • Understand the VHA Handbook 1108.2 requirements that relate to automation • Understand what reports should be requested from the pharmacy prior to performing a routine unit inspection • Understand what reports should be reviewed as part of the overall inspection process.
The Inspection Process • Requirements from VHA Handbook 1108.2 • Inspectors should have a password that permits access to the automated dispensing cabinets (ADC) only when accompanied by an authorized user • Inspectors must verify source data including a spot check of ADC removals • Report any unresolved discrepancies to the controlled substance coordinator for further investigation • Review resolved discrepancies for trending purposes • Review at least one day’s worth of ADC restocking
Inspecting an Automated Dispensing Cabinet • Written instructions on accessing the automated dispensing cabinet in use in your facility to perform a narcotic inspection is a handbook requirement.
Strategies for the Inspection Process • Temporary Password Set Up • When setting up passwords for the facility inspectors, they may be set up with a temporary password. • The password can be set up to expire within a selected amount of time.
Strategies for the Inspection Process • Permanent Password Set Up • The facility controlled substance inspectors may be set up with a permanent password that only allows the user to act as a witness. • This password will expire every 90 days similar to other passwords.
Conducting the Inspection • Area personnel should sign into the automated dispensing cabinet • The controlled substance inspector should sign on as a witness • Access the controlled substances stored in the cabinet. • Count the items in each drawer or pocket • Look for any discrepancy in count
Reports to Request for Inspection • Inspectors must verify source data including a spot check of ADC removals • The handbook requires that the inspectors verify provider orders in the inpatient or clinical setting • Request one day of activity for busy areas or a week to a month of activity for areas that use few controlled substances
Other Reports to Use in the Inspection of Specialty Areas • Specialty areas such as Operating Rooms, Cardiac Cath Labs or Colonoscopy Suites may require other reports to verify documentation of administration • OR Reports • Case Reports • Waste/Return Reports
Automation Specific Controlled Substance Activity Reports • AcuDose Rx: Controlled Substance Dispense Report • MedSelect: Controlled Substance Inventory Summary • Omnicell: Transactions by Date or Specific Criteria Report • Pandora: Med Usage Report/All Station Events • Pyxis: All Station Events
Delbert Siegmund, Pharm.D. Chief of Pharmacy Danville VAMC
Verifying Inpatient Orders in CPRS • Verify five randomly selected patients to make sure that there is an administration to a patient recorded for the dose(s) removed. • If your machine allows the addition of emergency or temporary cases, check to see that they are reconciled with the patient’s permanent records.
Verifying Inpatient Orders in CPRS • Access the patient and go to the “meds” or “orders” tab and find the order for the medication. • Double click on the order and scroll to the bottom of the “inpatient medication details” box. • Look for the date and time of the administration for the episode on your report
CPRS Screenshot of Inpatient Medication Details Scroll Down
BCMA Administration Reports • Available in BCMA under “Med Administration History” • Can also access “Med Administration Log” if the episode is recent • Both reports are available in CPRS on the “Reports” tab
Verification of Orders in Outpatient Areas • Outpatient Units • Colonoscopy Suite • Same Day Surgery • Cardiac Catheterization Suite • Work with HAS and Pharmacy to have clinic stop added to the unit • Area personnel should not have to add patients on a routine basis.
Verification of Orders in Outpatient Areas • Outpatient CPRS prescription (ex Methadone maintenance) • OR Report (Same Day Surgery) • Case Note (Cardiac Cath Lab, Colonoscopy Suite)
Jennifer Howard, Pharm.D. Director, Pharmacy Informatics San Diego VAMC
Methadone Maintenance Unit • AMS • Avatar System • Verify opening amount, amount dispensed, quantity on hand. • Verify 5 orders as previously outlined
Review Discrepancies • Ideally, you should also look at both unresolved and resolved discrepancy reports • Report any unresolved discrepancies to the controlled substance coordinator for further investigation • Review resolved discrepancies for trending purposes
Automation Specific Discrepancy Reports • AcuDoseRx: Discrepancy by Station, Open Discrepancy By Station • MedSelect: Top 25 discrepancies • Omnicell: Pharmacy Discrepancy Report • Pandora: Discrepancy Report • Pyxis: All Discrepancies
Verification of Restock • The handbook requires that the at least one days worth of restocking be verified as part of the inspection process. • A report of restocks will need to be generated from the Pharmacy narcotic vault. • This report may come from Vista, Pyxis CII Safe or Omnicell Secure Vault
Automation Specific Restock Reports • AcuDose Rx: Loading and Unloading Report • MedSelect: Restock Summary • Omnicell: Transactions by Date or End of Cycle Report (if site has Secure Vault) • Pandora: Narc Vault Reconciliation Report • Pyxis: Med Refill Activities
End of Shift Count • End of Shift Count or Weekly Count • Not a handbook requirement • May be required by local policy • End of shift discrepancy report • Best Practice
Inspecting the Pharmacy Narcotic Vault • Automation that may be present in the vault • Pyxis CII Safe or Omnicell Secure Vault • Fast Fill • Scriptpro SP50 • Baker Cells
Inspecting the Pharmacy Narcotic Vault • Pyxis CII Safe • Omnicell Secure Vault
Inspecting the Narcotic Vault • Pharmacy Dispense without (VA FORM 10-2638) • LORAZEPAM 0.5MG TAB,UD • Select NAOU: xx • QUANTITY DISPENSED (TAB/25): 25// 25 • JAN 01, 2001@08:21:51 DISP OMNICELL XX • -25
Outpatient Robotic Prescription Fill • Fast Fill • Baker Cells • ScriptPro
Questions??? • Marian Daum - Coatesville VAMC • Delbert Siegmund - Danville VAMC • Jennifer Howard - San Diego VAMC • Dionne Roney - Charleston VAMC • Jolene Hallcroft - Sheridan VAMC