Handling and Monitoring of Dangerous Drugs

COVERAGE: This policy shall apply to all Doctors, Nurses, Pharmacists and all healthcare providers involve in prescribing, ordering, dispensing, administering and/or monitoring effects of dangerous drugs. PURPOSE: 1. To provide guidelines in ordering, prescribing, dispensing, administering and disposal of excess, unused and expired dangerous drug in accordance to the provisions of the Republic ct No. !1"# also $no%n as &'omprehensive Dangerous Drug ct of ())(.* (. To provide guidelines for the proper accounting of dangerous drugs. +. To assure proper usage and handling of dangerous drug. POLICIES AND PROCEDURES: A PRESCRI!ING DANGEROUS DRUGS a.1 ttending Physician and/or resident Physician shall provide the patient %ith the right prescription needed for the dangerous drugs. a.( ttending Physician and/or Resident Physician shall possess and valid ,( license %hen prescribing a dangerous drugs. -nly physicians %ith valid ,( license may %rite prescriptions for dangerous drugs. .Please refer to nnex / 0 1o% to chec$ the validity of ,( 2icense.3 a.+ Physician %ill %rite orders for dangerous drugs in the Doctor4s -rder ,heet. a.5 Physician shall %rite completely the follo%ing information a.5.1. Name of the Patient a.5.(. Room Number a.5.+. Date of the prescription a.5.5. 6eneric and /rand Name a.5.#. Dosage strength and form a.5.". 7uantity a.5.8. Diagnosis if for cancer patient a.5.9. Name and ,ignature of the prescribing physician a.5.!. PTR Number a.5.1). :alid ,( 2icense in the prescription.

a.#. Physician shall countersign any erasures/alterations in the prescription. a.". Physician shall endorse the prescription to the medication nurse.

RE"UISI#ION$ PREPARA#ION AND DISPENSING O% DANGEROUS DRUGS

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

! & %loorsto'(s )OR*DR*ER*MICU+ 1. Dangerous drugs that are part of the floorstoc$s shall be re;uested through the -nline ,upply Re;uisition. The -nline ,upply Re;uisition shall be sent by the re;uesting units to the Pharmacy Department.

(.

ll speciali<ed areas shall complete all the re;uirements needed by the Pharmacy. The Pharmacist %ill only prepare the re;uested dangerous drug only upon chec$ing and accepting the valid and complete re;uirements %hich are as follo%s0 = = = = :alid Prescription .ordinary or D-1 yello% prescription3 ccomplished nnex >orm

?mpty vials and its corresponding Dangerous Drug @astage >orm . nnex AAA3 Anventory Production report accomplished by special area .-R/DR/?R/A'B3.

+.

ll -nline ,upply Re;uisition for dangerous drug shall be served from Conday to ,aturday, !0)) C to #0))PC upon submission of complete re;uirements to the Pharmacy.

5. -nly the 1ead Nurses and his/her designated -A's are the authori<ed personnel to claim the re;uested dangerous drugs. An the absence of the 1ead Nurse/-A', the ,enior Nurse shall be allo%ed to claim the dangerous drugs provided that there is a letter of authori<ation signed by the 1ead Nurse/ -A'.

#. The authori<ed recipient shall sign on the Receiving Portion of the c$no%ledgement ,heet upon receipt of the dangerous drugs.

nnex

>orm and Transfer

". ?ach unit shall maintain an updated nnex >orm for each issuance of dangerous drugs to serve as a proof=of=use disposition records. The nnex >orm shall completely filled up and record the follo%ing0

= = = = =

Patient Name Room Number dministered Dose Date and Time dministered >ull Name of Prescribing Physician

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

= = =

:alid ,( Number and its validity date of the Prescribing Physician ,ignature of dministering Nurse 'orresponding balance per issuance

8. Pharmacist shall chec$ the follo%ing re;uirements if valid and complete0 = Dello% prescription %ith :alid ,( 2icense number of prescribing = ccomplished nnex >orm = Anventory Production Report .for Ceperidine, ,odium Thiopental, Eetamine vial3 = ?mpty vials and its corresponding Dangerous Drug @astage >orm . nnex AAA3 Note0 if not complete, Pharmacist shall call and inform the 1ead Nurse. 9. Pharmacist shall counterchec$ the Dangerous Drug Dispensing Record . nnex 3 >orm for accuracy of entry. = 'hec$ for any erasures/alterations, should be countersigned by administering /recording nurse. = :alidity of ,( 2icense of prescribing doctor = ll columns should be completely filled up !. Pharmacist shall chec$ and print the -nline ,upply Re;uest per unit in three copies. = -ne copy for the re;uesting unit = -ne copy for Pharmacy = -nce copy for ccounting 1). Pharmacist shall prepare and accomplish .type%ritten3 the ne% nnex >orm for Dangerous Drug Dispensing Record by indicating the follo%ing0 = Name of Dangerous Drug and prescription serial number = 'ontrol Number of nnex >orm = Date, mount and 7uantity dispensed = mount carried over for multiple dose vials = Re;uesting unit = Name and ,ignature of Dispensing Pharmacist = Name and ,ignature of Receiving Nurse Note0 Pharmacist %ho chec$s correctness and completeness of the nnex form shall affix her signature on the &/alance column.* 11. Pharmacist shall fill and dispense according to the approved prescription limits per drug to receiving nurse of re;uesting unit. .Refer to 2ist of Dangerous Drug and their Prescription 2imits3. ll dangerous drugs shall be pac$ed and labelled %ith &1A61 2?RT C?DA' TA-N,*. 1(. Pharmacist shall indicate the transaction number in the yello% prescription. 1+. Pharmacist shall dispense the approved re;uested dangerous drug to re;uesting units. 15. Pharmacist shall encode the ;uantity and expiration date of drug dispensed in -nline ,upply Re;uisitions.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

1#. The receiving nurse shall encode his/her employee number to ac$no%ledge receipt of item in the system and %ill sign on the printed form. 1". Pharmacist shall file all the yello% prescription and annex form for recording and documentation.

! , Indi-idual Patient Re.uest /0 Nursing Stations 1. Dangerous Drug ordered in the Doctor4s -rder ,heet for a particular in=patient shall be re;uested to the Pharmacy thru -nline Patient -rder ,ystem. Nurse4s re;uest order shall be good for 9 hours only.

(. The Nurse must secure that the prescription .D-1 Dello% or -rdinary Prescription3 is completely filled up by the prescribing physician.

+. Nurse shall separate the re;uest of dangerous drug from other regular medicines of the patient to avoid the delay in dispensing the regular medicines that don4t need special re;uirements.

5. -nly uthori<ed 2icense Nurses are allo%ed to claim dangerous drugs from the Pharmacy Department. ll re;uested order .either as standing order/ e=cart replacement3 must be claimed from the Pharmacy %ithin 9 hours after the posted online re;uest. Pharmacy %ill return in the system all unclaimed posted charges after (5 hours from the time it %as re;uested.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

#. The Pharmacist shall prepare the re;uested dangerous drugs only upon retrieval by the Nurses. nother Pharmacist shall counterchec$ the prepared re;uest prior to issuance.

". Bpon issuance to the Nurse, Pharmacist shall completely accomplish the nnex dangerous drugs dispensed.

form for each

Note0 ,afe$eeping of the nnex >orm 'opy of all Nursing ,tations are $ept by the Pharmacy except for CA'B/ -R/ DR/ ?R.

8. The Nurse shall sign on the &Receiving portion* of the 'harge Tic$et and the receipt of the dangerous drug. ! 1 Re.uisition of Me2eridine )De3erol+ -ial fro3 Nursing Stations

nnex >orm upon

1. ,ince the nursing station has no charging capacity of fractional dose from multiple dose vials li$e Demerol, the 1ead Nurse of the nursing station shall re;uest Demerol vial through Canual Re;uisition ,lip. (. The 1ead Nurse shall accomplish the follo%ing re;uirements prior to the submission to Pharmacy. = Canual Re;uisition ,lip = D-1 Dello% Prescription = ccomplished nnex >orm = ?mpty vials of Demerol and its corresponding Dangerous Drug @astage >orm . nnex AAA3 = -riginal 'harge tic$ets as a proof=of=charging to individual patients = Anventory Production report %ill be accomplished by the Pharmacy for Nursing ,tations. +. The Pharmacist shall prepare the re;uested dangerous drugs only upon retrieval by the Nurses. nother Pharmacist shall counterchec$ the prepared re;uest prior to issuance.

5. The Nurse shall sign on the &Receiving portion* of the Canual Re;uisition ,lip and the >orm upon receipt of the Demerol vial.

nnex

SECURI#4 AND S#ORAGE 1. ll dangerous drugs used %ithin the hospital should only come from the Pharmacy Department.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

(.

ll staff involves %ith the handling of dangerous drugs must be reminded of their responsibilities for the safe custody and proper documentation and administration necessary for those drugs. ll dangerous drugs must be secured on Nursing Bnits and Pharmacy in an appropriate location and must be double loc$ed at all times.

+.

5. The Eeys of the double loc$ed cabinet must be $ept and carried by the 1ead Nurse/-A' at all times. The Nurse should not ta$e the $eys %ith him/her %hen he/she leaves the unit. #. The Eeys must be given to the incoming authori<ed nurse by the end of every shift and after the count is done. The $ey must not be left unattended in the dra%er or other area. ". The 1ead Nurses/ -A's shall be accountable for the security of dangerous substance issued to their respective units. ll re;uired documentation and proper papers assuring the accuracy and proper handling of the dangerous drug is full responsibility of the nurse supervisor and 1ead Nurse/-A' of each unit.

8. The An=charge nurse from the incoming shift and the An=charge nurse from the outgoing shift must count all dangerous drugs at the beginning of each shift as part of endorsement.

9. >or ,peciali<ed reas, ll unused dangerous drugs shall be returned to the double loc$ed cabinet after each procedure. N- dangerous drugs shall be left inside the anaesthesia or procedure room carts %hen not in use. !. >or Nursing ,tations, retrieval of dangerous drugs from the double loc$ed cabinet shall be done prior to administrations. No dangerous drugs shall be left in the medication box %hen not in use. D Do'u3entation of 5astages 1. ll dangerous drugs are disposed for the follo%ing reasons. i. Bnused dose remaining after administrations ii. 'ontaminated iii. Dra%n=up but not administered iv. Doses refused by the patient (. ?xcess substance/%astage incurred shall be documented in the appropriate Dangerous Drug Conitoring >orm . nnex AAA3. +. The administering nurse shall completely accomplish the form. 5. nother licensed or authori<ed staff shall %itness and observe the entire disposal of %aste and affixes his signature on the form.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

>or -R and DR F %itness %ill be naesthesiologist >or Nursing ,tations F Nurse ,upervisor or Pharmacist in the absence thereof #. ll %astage shall be disposed in the sharps collector, sin$ or toilet bo%l. The disposal must render the product unrecoverable. i. ii. iii. Remaining solutions shall be aspirated and disposed in sin$ or toilet bo%l. -ral medications shall be pulveri<ed prior to disposal in sin$ or toilet bo%l. >entanyl patches should be folded in half %ith the stic$ sides together and disposed in the sharps container. The nurse removing the patch should be careful not to touch the stic$y side of the patch. A: tubing containing a controlled substance shall be evacuated thoroughly and discarded

iv.

". The Dangerous Drug Conitoring >orm shall be filed by the Nursing units and Pharmacy for future reference.

8.

ll ?xpired dangerous drug shall be surrendered by the Pharmacy to Dangerous Drug /oard for disposal accompanied by the follo%ing documents0 i. ii. iii. 2etter addressed to the Dangerous Drug 'ustodian informing of the surrender. Name, ;uantity and reason for surrender should be indicated. Dangerous Drug Record /oo$ for notation.

RECORDING AND REPOR#ING

1.

ll dangerous drugs received, dispensed, administered and disposed must be recorded in accordance to the provisions of the &'omprehensive Dangerous Drugs ct of ())(*.

(. Pharmacy must $eep an original record of sales, purchases, ac;uisitions and deliveries of dangerous drugs indicating the follo%ing information0 i. ii. 2icense Number and address of the pharmacist Name, address and license of the manufacturer, importer or %holesaler for %hom the drug %as purchased. 7uantity and name of the drug purchased Date of Purchase

iii. iv.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

v. vi. vii. viii.

Name, address and community tax certificate of buyer ,erial number of the prescription, name of the physician 7uantity and name of drug sold Date of ,ale

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semi=annual report shall be submitted by the Pharmacist to the Philippine Drug ?nforcement gency .PD? 3 %ithin 1# days follo%ing the last day of Gune and December of each year. The semi=annual report should have the follo%ing information0 Anclusive date of the ;uarter ending Name of 1ospital ddress of the 1ospital Name of the drug ,toc$ on hand Total ;uantity purchased >rom %hat company it %as purchased Total ;uantity dispensed during the ;uarter /alance on hand

= = = = = = = = =

!REA6AGE AND LOSSES

1. An case of loss due to brea$age of the container or through other accidents, the person in possession and responsibility for the drug repose at that time shall inform the Philippine Drug ?nforcement gency of such incident thru the Pharmacy Department by telephone or other possible means %ithin t%enty=four .(53 hours from the time of the incident or its discovery. n affidavit in ;uadruplicate indicating the $inds and ;uantities of the dangerous drugs and the circumstances involved shall be for%arded to the Philippine Drug ?nforcement gency %ithin seventy=t%o .8(3 hours from the time of occurrence or discovery of the incident.

(. The responsible person shall submit the affidavit of loss/brea$age together %ith the Dangerous Drug /oo$ of the said drug to the Philippine Drug ?nforcement gency .PD? 3 for proper recording. An case of brea$age, the bro$en container of the drug shall also be submitted to the PD? .

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

+. An case of loss due to theft or robbery, documentary evidence that the local police authorities %ere notified shall accompany the affidavit.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())

HO5 #O CHEC6 S, LICENSE VALIDI#47 )Anne8 !+

Dear issued 'ontrol No. .Temporary ,( H does not possess control no.3

"=digit Permanent No.

,( No0 HHHHHHNC11 = HHHRHH = 2H

@here N I Ne% -r R I Rene%al -r ? I ?xempt

2oss as reported

Region %here processed/issued

@here C I Cedical Practitioner/Physician -r D I Dentist -r : I :eterinarian

S, Li'ense Codes
JJJJJJN C 1) JJJJJJN D 1) JJJJJJN : 1) temporary ,( license H .valid %ithin 1# days only3

JJJJJJN C 1) JJJ JJJJJJN D 1) JJJ JJJJJJN : 1) JJJ

1.

,( license H valid until PR' expiry .for gov4t K private3

?xample FAf ,( license is 1()5)R)9 or 1()5)N)9, it %as issued December 1+, ())9 and valid until December +1, ()1) =)9 means year on %hich the ,( license %as issued and valid %ithin + years on the month of December ?xample F Af ,( license is 1()5)RC1) or 1()5)NC1), it %as issued December 1+, ()1) and valid until December (9, ()1) =Temporary ,( license valid %ithin 1# days only. ?xample F Af ,( license is 1()51NC1)=))), it is valid until JJJJJ()1( .+ years3 on the birth month of the licensed doctor. PD? ,C, 7B?RD To register PD? R?6.space32 ,TN C?.space3>AR,TN C?.space3CADN C?.space3/D D.mm/dd/yyyy format3 send to )!18=9(88++( )!18=9',PD? Cessage after registration0

(.

+.

HANDLING AND MONITORING OF DANGEROUS DRUGS Prepared By: POLICY AND PROCEDURES Dianna Grace N. Cruz, RPh P AR!ACY DEPAR"!EN" Sep#e$%er &', &())