Section Pharmacy

Sub-section

SANTA BARBARA COUNTY D EPART M ENT OF

Behavioral Wellness A System of Care and Recovery

Policy

Policy#

Pyxis MedStation Medication Removal and Return

17.103

Page 11 of 3

Programmatic Policy and Procedure

Effective: 9/12/2018

Version: 1.0

Last New Policy Revised:

Director's Approval --........+----~-----.---......_ ______ _ Ali~iC):?

1JJJ~ Pharmacist-in­Charge Approval

Morgan Peterson, PharmD

Supersedes: New policy

1. PURPOSE/SCOPE

Date

Audit 9/12/2021 Date:

1.1 . To establish Pyxis MedStation medication removal and return standards at Santa Barbara County Department of Behavioral Wellness sites (hereafter the "Department").

1.2. This policy applies to all Santa Barbara County Mental Health Services Pharmacy (hereafter the "Pharmacy") staff, Department program staff, and any other persons acting on behalf of the Department who utilize a Pyxis Med Station at their assigned site.

2. DEFINITIONS

2.1. Pyxis MedStation - an automated dispensing system that performs the storage, dispensing, and distribution of medications.

2.2. Profiled station - sites in which medication removal from the Pyxis MedStation is restricted to those medications ordered by a prescriber for a specific patient and reviewed and approved by the Pharmacy.

2.3. Unit dose packaging - a method of single medication dose delivery in non-reusable containers. Unit dose packaging is used for both liquid and solid medications. Examples of packaging include, but are not limited to, blister cards, bubble packs, vials, and prefilled syringes.

3. POLICY

3.1. · Medications shall be removed from and returned to the Pyxis MedStation system in accordance with all relevant federal and state laws, regulations, and other requirements, as well as standards of clinical and pharmacy practice.

Santa Barbara County Department of Behavioral Wellness Office of Quality and Strategy Management

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Santa Barbara County Department of Behavioral Wellness Office of Quality and Strategy Management

4. MEDICATION REMOVAL 4.1. All medication must be removed from the Pyxis MedStation under the name of the

patient who is to receive the medication.

4.2. For profiled stations, the prescriber’s medication order will be sent to the Pharmacy in a timely fashion. The Pharmacy will review and approve medication orders in a timely fashion but no later than by the end of business day. Critical override should only be utilized afterhours when the Pharmacy is closed or for critical medications.

4.3. Staff will remove only the quantity of medication that they have inputted into the Pyxis MedStation to avoid creation of discrepancies or inventory errors.

4.4. Staff will have the medication order or Medication Administration Record (MAR)

available by the Pyxis MedStation to compare order information and ensure accuracy.

5. MEDICATION RETURNS 5.1. Pyxis MedStation medications not administered to patients are returned to the Pyxis

MedStation.

5.2. Controlled substances1 removed from the Pyxis MedStation but not administered to the patient are returned to the bin designated specifically for returned controlled substances. A second licensed nursing staff (LNS) is required as a witness when returning controlled medications. 1. If the original unit dose packaging is not intact, the medication cannot be returned to

the Pyxis MedStation and must be disposed of in accordance with site-specific medication disposal/destruction policies and with appropriate documentation as required.

5.3. When a pharmacist verifies the accuracy of controlled substance returns when the

designated return bin is emptied, a LNS or Pharmacy staff must serve as a second witness. Once the controlled substances have been verified, they can be placed back into the Pyxis MedStation inventory or sent back to the Pharmacy.

5.4. Medications cannot be returned if they have entered a room in which the patient is on

Isolation Precautions. In this instance, staff will discard the medication in accordance with site-specific medication disposal/destruction policies.

1 Please refer to the Pharmacy’s policy “Pyxis MedStation Controlled Substances” for further details.

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Santa Barbara County Department of Behavioral Wellness Office of Quality and Strategy Management

ASSISTANCE Morgan Peterson, PharmD, Pharmacist-in-Charge

REFERENCES Pyxis MedStation™ 4000 System – Console User Guide (November 2010) California Business and Professions Code Section 4105.5 California Health and Safety Code Section 1261.6(c)(d)(1) RELATED POLICIES Pyxis MedStation Controlled Substances Pyxis MedStation Medication Storage, Inventory and Restocking

REVISION RECORD

DATE VERSION REVISION DESCRIPTION

Culturally and Linguistically Competent Policies The Department of Behavioral Wellness is committed to the tenets of cultural competency and understands that culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse individuals. All policies and procedures are intended to reflect the integration of diversity and cultural literacy throughout the Department. To the fullest extent possible, information, services and treatments will be provided (in verbal and/or written form) in the individual’s preferred language or mode of communication (i.e. assistive devices for blind/deaf).