pharmacy informatics workgroup pharmacy automation guidance for the controlled substance coordinator...
TRANSCRIPT
![Page 1: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/1.jpg)
Pharmacy Informatics Workgroup
Pharmacy Informatics Workgroup 1
PHARMACY AUTOMATION
GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR
Part 1: The Inspection Process
![Page 2: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/2.jpg)
Pharmacy Informatics Workgroup
2
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.
![Page 3: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/3.jpg)
Pharmacy Informatics Workgroup
3
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
![Page 4: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/4.jpg)
Pharmacy Informatics Workgroup
4
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.
![Page 5: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/5.jpg)
Pharmacy Informatics Workgroup
5
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.
![Page 6: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/6.jpg)
Pharmacy Informatics Workgroup
6
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.
![Page 7: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/7.jpg)
Pharmacy Informatics Workgroup
7
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
![Page 8: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/8.jpg)
Pharmacy Informatics Workgroup
8
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
![Page 9: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/9.jpg)
Pharmacy Informatics Workgroup
9
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
![Page 10: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/10.jpg)
Pharmacy Informatics Workgroup
10
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
![Page 11: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/11.jpg)
Pharmacy Informatics Workgroup
Pharmacy Informatics Workgroup 1
1
Delbert Siegmund, Pharm.D.
Chief of PharmacyDanville VAMC
![Page 12: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/12.jpg)
Pharmacy Informatics Workgroup
12
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.
![Page 13: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/13.jpg)
Pharmacy Informatics Workgroup
13
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
![Page 14: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/14.jpg)
Pharmacy Informatics Workgroup
14
CPRS Screenshot of Meds Tab
![Page 15: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/15.jpg)
Pharmacy Informatics Workgroup
15
CPRS Screenshot of Inpatient Medication Details
Scroll Down
![Page 16: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/16.jpg)
Pharmacy Informatics Workgroup
16
CPRS Screenshot of Inpatient Medication Details cont.
![Page 17: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/17.jpg)
Pharmacy Informatics Workgroup
17
CPRS Screenshot of Inpatient Medication
Details (IV example)
![Page 18: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/18.jpg)
Pharmacy Informatics Workgroup
18
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
![Page 19: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/19.jpg)
Pharmacy Informatics Workgroup
19
BCMA Medication Admin History Report
![Page 20: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/20.jpg)
Pharmacy Informatics Workgroup
20
BCMA Reports available in CPRS – Reports Tab
![Page 21: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/21.jpg)
Pharmacy Informatics Workgroup
21
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.
![Page 22: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/22.jpg)
Pharmacy Informatics Workgroup
22
Verification of Orders in Outpatient Areas
Outpatient CPRS prescription (ex Methadone maintenance)
OR Report (Same Day Surgery) Case Note (Cardiac Cath Lab,
Colonoscopy Suite)
![Page 23: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/23.jpg)
Pharmacy Informatics Workgroup
23
Jennifer Howard, Pharm.D.Director, Pharmacy Informatics
San Diego VAMC
![Page 24: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/24.jpg)
Pharmacy Informatics Workgroup
24
Methadone Maintenance Unit
AMS Avatar System
Verify opening amount, amount dispensed, quantity on hand.
Verify 5 orders as previously outlined
![Page 25: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/25.jpg)
Pharmacy Informatics Workgroup
25
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
![Page 26: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/26.jpg)
Pharmacy Informatics Workgroup
26
Automation Specific Discrepancy Reports
AcuDose Rx: Discrepancy by Station, Open Discrepancy By Station
MedSelect: Top 25 discrepancies Omnicell: Pharmacy Discrepancy
Report Pandora: Discrepancy Report Pyxis: All Discrepancies
![Page 27: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/27.jpg)
Pharmacy Informatics Workgroup
27
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
![Page 28: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/28.jpg)
Pharmacy Informatics Workgroup
28
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
![Page 29: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/29.jpg)
Pharmacy Informatics Workgroup
29
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
![Page 30: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/30.jpg)
Pharmacy Informatics Workgroup
30
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
![Page 31: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/31.jpg)
Pharmacy Informatics Workgroup
31
Inspecting the Pharmacy Narcotic Vault
Pyxis CII Safe
Omnicell Secure Vault
![Page 32: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/32.jpg)
Pharmacy Informatics Workgroup
32
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
![Page 33: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/33.jpg)
Pharmacy Informatics Workgroup
33
Outpatient Robotic Prescription Fill
Fast Fill Baker Cells ScriptPro
![Page 34: Pharmacy Informatics Workgroup PHARMACY AUTOMATION GUIDANCE FOR THE CONTROLLED SUBSTANCE COORDINATOR Part 1: The Inspection Process 1](https://reader035.vdocument.in/reader035/viewer/2022062619/55189cfb550346a61f8b46e6/html5/thumbnails/34.jpg)
Pharmacy Informatics Workgroup
34
Questions???
Marian Daum - Coatesville VAMC
Delbert Siegmund - Danville VAMC
Jennifer Howard - San Diego VAMC
Dionne Roney - Charleston VAMC
Jolene Hallcroft - Sheridan VAMC