059-12 Wyo. Code R. §§ 12-22 - Controlled Drugs

(a) All controlled substances issued by the institutional pharmacy to any institutional facility department, excluding those controlled substances for which the dispensing and record-keeping are maintained utilizing an automated drug dispensing device, shall be labeled and accompanied with control sheets (proof of use forms) that provide space for recording:

(i) The drug name, strength, and dosage form;

(ii) The date and time of administration;

(iii) The quantity administered;

(iv) Name of patient;

(v) The signature of the nurse who administered the medication, when issued to nursing units; and

(vi) The signature of the practitioner who administered the medication and a witness, when issued to surgery or other specialized areas such as endoscopy labs.

(b) Such drugs shall be limited both in kind and quantity commensurate with the needs of the area to which they are distributed; the institutional pharmacy shall maintain a record of such distribution. The PIC, in consultation with the director of nursing or other appropriate hospital staff, shall establish written requirements for the frequency of controlled substance inventories in drug storage areas outside of the institutional pharmacy.

(c) All control sheets must be returned to the institutional pharmacy upon completion. The pharmacist shall verify the returned sheets for accountability and control prior to drug reissuance. These control sheets, as well as any records generated, must be maintained so as to be readily retrievable at the institutional pharmacy for two (2) years. Records of controlled substance, which are dispensed utilizing an automated dispensing device, shall be maintained at the institutional pharmacy for two (2) years.

(d) All controlled substances that must be wasted shall be destroyed by a method approved by the PIC. Documentation of all destruction must occur on the control sheet, in the patient's medical record, or utilizing the format available with an automated drug dispensing device, and be signed (written or electronically) by the nurse/physician destroying and one witness who observed the destruction.

(e) Transdermal patches containing controlled substances shall be handled in the following manner:

(i) The PIC, in coordination with the director of nursing, will implement a policy requiring all nursing personnel applying a transdermal patch containing a controlled substance to write the date on the patch when it is first applied to a patient.

(ii) All used transdermal patches containing a controlled substance shall be destroyed in front of a witness, and documented. The destruction will be done in a manner currently recommended by the FDA.

Notes

059-12 Wyo. Code R. §§ 12-22