TABLE OF CONTENTS Policy/Purpose 1 Procedure 2 · 2018-09-19 · POLICY WRH Universal (WRU)...

POLICY

WRH Universal (WRU)

Document Title: Automated Dispensing Devices (Pyxis) Policy Number: PH14-6

Department: Pharmacy of 13

Author: Mary Beth Michailoff, (Manager, Pharmacy)

Authorized By: Christine Donaldson (Director, Pharmacy) Claudia DenBoer-Grima (VP, Pharmacy)

Origination Date: 03/01/2003 Effective Date: 07/01/2014 Next Review Date: 12/01/2018 Revision/Creation Date: 07/01/2014

All hard copies of this document to be considered REFERENCE ONLY. Always refer to the WRH Intranet Policy & Procedure Library for the latest version.

Automated Dispensing Devices -Pyxis Policy

TABLE OF CONTENTS

Policy/Purpose ........................................................................................................................................... 1

Procedure .................................................................................................................................................. 2

Healthcare Provider .................................................................................................................................. 2

Nursing Instructor and Student Nurse Access ........................................................................................ 4

Respiratory Therapist Access ................................................................................................................... 4

Midwife Access ........................................................................................................................................... 4

Anesthetist Access ...................................................................................................................................... 4

Narcotics, Benzodiazepines and Controlled Drug Removal .................................................................... 6

Restocking Narcotics ................................................................................................................................... 6

Narcotic Wastages ....................................................................................................................................... 6

Returning Medications ................................................................................................................................ 6

Narcotic Discrepancies ................................................................................................................................ 6

Miscellaneous ............................................................................................................................................. 7

Automatic Stop Orders (ASO’s) ................................................................................................................ 7

Medication Overrides .................................................................................................................................. 7

Emergency Downtime ................................................................................................................................. 8

Recovering a Failed Drawer ....................................................................................................................... 8

Adding a Patient .......................................................................................................................................... 8

Appendix A: Hospital staff-Pyxis ID/Password assignment ................................................................. 9

Appendix B: Student Nurses-Pyxis ID/Password assignment ............................................................ 10

Appendix C: Nursing Instructors-Pyxis ID/Password assignment .................................................... 11

Appendix D: Pyxis Monthly Manual Narcotic Count ......................................................................... 13

POLICY/PURPOSE Automated dispensing devices are recognized at the Windsor Regional Hospital as a technology that will increase patient safety, reduce medication errors, improve security and reduce costs by reducing drug wastage and excess storage. It is vital to the success of this technology that all staff using it has sufficient training. It is just as important that these procedures are followed to allow for the best flow of information between the staff and the pharmacy department.

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PROCEDURE

Healthcare Provider

A. Medical staff working in areas with Automated Dispensing Devices (ADD's) will have access to the PyxisMedstations at Windsor Regional Hospital. Authorization is granted to the following Healthcare providers but notlimited to: RN. RPN, Respiratory Technicians, Midwives, Pharmacy Technicians, Pharmacists and Physicians.Access for Anesthetists, Nurse Instructors and Student Nurses: refer to appropriate section within the Policy

B. To be activated on a Pyxis Medstation, a Pyxis Tutorial certificate along with the appropriate Pyxis Password formmust be submitted to Pharmacy :

a. Appendix A – Staff ID/Password Formb. Appendix B – Pyxis ID/Password Assignment Information Pertaining to Student Nursesc. Appendix C – Pyxis ID/Password Assignment Information Pertaining to Nursing Instructors

C. TAKING THE PYXIS TUTORIAL:a. The Pyxis tutorial may be completed in the following different methods

1) through Citrix – Main Menu > Clinicals > Pyxis Medstation 4000 Training icon2) Ouellette Campus Library – loaded on computer desk top3) Pyxis Medstation – “P’ icon on screen & follow instructions4) University of Windsor & St. Clair College computers.

D. Each user of Pyxis will have a unique personal identification that will be assigned by Pharmacy

E. The Manager (Program/Department) is responsible for ensuring that all permanent staff has access to their PyxisMedstation.

F. INITIAL ACCESS TO PYXIS:

- Enter your ID as assigned by Pharmacy- Your temporary password will be assigned by Pharmacy- You will be instructed to change your temporary password (minimum of 6 characters and maximum of 8

characters)(not case sensitive and any combination of numbers and letters)

You will follow prompts to register your Biometric ID:

- Using the same finger cover the entire scanning lens with your fingertip- Apply firm consistent pressure on the scanner- If your hands and fingers are cold, rub them together to warm them up before using the scanner

G. LOGGING ON TO PYXIS:

- Touch the station screen to clear the screen saver- Type your User ID and press Enter- Employees must use their Biometric ID (fingerprint) instead of their password.

To successfully register fingerprint images or to log in at a station: - Using the same finger cover the entire scanning lens with your fingertip- Apply firm consistent pressure on the scanner- If your hands and fingers are cold, rub them together to warm them up before using the scanner.

H. LOGGING OUT OF PYXIS:

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- Select Exit in the upper right corner of the screen- AVOID unauthorized removals using YOUR NAME. ALWAYS LOG OUT.

I. TO CHANGE YOUR FINGERPRINT ID AT THE STATION

- on user menu: press “change Biometrics”- enter password- press scan- follow instructions on the screen to register your BIO ID:- No record of your fingerprint is stored.

J. IF YOUR FINGERPRINT DOES NOT WORK:

- Some Users are not able to register a Biometric Scan.- Failed attempts must be observed by Pharmacy staff prior to changing from Biometrics to password

Passwords must never be given to another individual. In cases where the user forgets theirpassword, the hospital requires the user go to the pharmacy in person with their ID-Badge to have thepassword reset.

K. CHANGING PASSWORDS:

- If at any time you believe the security of your password has been breached you must change your passwordimmediately.

-From the Main Menu, select User Menu-From the user Maintenance Menu select Change Password and follow the instructions.

- If you do not remember your Password, you must go to the Pharmacy in person along with your Hospital IDand the Pharmacy Manager will make appropriate changes

L. TEMPORARY USERS:

All RN’s & RPN’s can ACTIVATE temporary access to current users of Pyxis. Temporary users will be restrictedto 14 hours of use (at least one shift) on that unit’s Medstations.

If a nurse floats to another Pyxis unit, they may be activated as a temporary user. If this is a commonoccurrence, the Nurse Manager /Clinical Manager must email Pharmacy Management to assign accessto that area (i.e. ER and ICU designation).

NEW USERS TO PYXIS WILL ONLY BE ADDED BY PHARMACYNEW STUDENTS AND INSTRUCTORS OR ASSIGNMENT CHANGES WILL ONLY BEADDED BY PHARMACY

M. STAFF CHANGES IN YOUR AREA:

To maintain the security of the Pyxis system, a Department Manager and or Human Resource Department willnotify Pharmacy Management of the following:

1) Staff no longer employed/terminations/retired2) Staff on a Leave of Absence3) Staff with name changes4) Staff who are transferring to another nursing unit

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Nursing Instructor and Student Nurse Access

At the beginning of each semester, Pharmacy will require a copy of the Pyxis tutorial along with the completed Appendix Volunteer Services will provide Pharmacy with a list of instructors and students along with their start and stop dates of their rotation at Windsor Regional Hospital. a. Volunteer Services will provide each student with a unique ID number which will be used along with your initials

to access Pyxis.Example: Mary Smith 12345 = MS12345Nursing Instructors will provide Pharmacy with the Pyxis tutorials and the signed Pyxis ID forms for themselvesand the students (Appendix B and C) at least 2 weeks prior to the start of the rotation. Nursing InstructorsMUST NEVER use their WRH login while acting as an Instructor.

b. Pyxis access will last the length of their rotation and the expiry date will be entered into the Pyxis system byPharmacy.

c. ANY CHANGES TO THE STUDENTS OR INSTRUCTORS ASSIGNEMENT MUST GO THROUGHVOLUNTEER SERVICES

d. Student and WRH Medication Use policy will govern the removal and administration of medications.

Respiratory Therapist Access Respiratory Therapist access will be limited to those medications within the scope of their practice

Midwife Access Midwives access will be limited to those medications within their scope of practice

Anesthetist Access a. Anesthetists with privileges and requiring access to the Automated Dispensing Devices (ADD's) will have access

to select Pyxis Medstations at Windsor Regional Hospital. All medications removed/administered will bedocumented on the appropriate section of the patients chart. In addition, all removals of Narcotics andControlled Substances will be documented on the Narcotic and Controlled Drug Administration Record. Thiscompleted record (documentation of usage and wastage) must be returned to the Return Bin at the end of theshift in a zip lock bag along with any unused narcotics

b. Anesthetists will begin their removal process by removing their Narcotic Administration Recordc. Subsequent removals will require the input of the correct record number located on the top of the Narcotic

Administration Recordd. Pharmacy will empty the return bins and reconcile ALL Narcotic Administration Records.e. Any records missing any information eg. Signatures, dates etc. will be returned to the Physician to completef. Any records that do not accurately add up ( total volume removed should equal total volume administered)

will be returned to the Physician to accurately complete

User ID will be your 1st

initial of your first name and your last name:e.g. Richard Jones = RJONES

MEDICATION REMOVAL

a. To remove medications for patients in a “non-profiled area”:1) Select “Remove” from the Main Menu2) Select your patient from the “Select a Patient” screen (or type first few letters of the patients last name)

**CONFIRM THE CORRECT PATIENT BY VERIFYING AGAINST 2 PATIENT IDENTIFIERS3) Type in the name of the medication ordered: the enhanced medication list allows you to search a

medication list containing both brand and generic names4) From the list of medications on the screen, “touch” the med on the screen to be removed.5) Select “Remove” (the drawer will open in sequence for each medication chosen)

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b. To remove medications for a patient in a “profiled area”: “A profiled medication is a medication order that has beenscreened and approved by a pharmacist “

1) Select “Remove” from the Main Menu2) Select your patient from the “Select a Patient” screen (or type first few letters of the patients last

name) ** CONFIRM THE CORRECT PATIENT BY VERIFYING AGAINST 2 PATIENT IDENTIFIERS3) From the patient’s profile, select all the medications you plan to administer.4) Select Remove (the Pyxis drawers will open in sequence for each medication chosen)5) READ SCREEN FOR CORRECT POCKET LOCATION. (More than one medication may be

stored in each drawer)

c. Medications are to be removed from Pyxis and administered to one patient at a time. When possiblemedications will be brought to the patient’s bedside still in the package to allow for a double check at the time ofmedication administration. As you remove each medication place the unopened package in the individualmedication cup. For medications that require crushing, bring the empty packages to the bedside for confirmation.All intact medications can be returned to the Pyxis system in the return bin if the package is not opened.

d. During the medication retrieval, a patient’s ordered medication may appear to be greyed out on the Medstationscreen. By touching the “greyed out” medication a reason will appear at the bottom of the screen such as :

i. Are not loaded in the Pyxis Medstation. These medications will be kept in the refrigerator or thepatient’s medications bins/cupboards. “ Med not available will appear on the screen”

ii. Are loaded in your Pyxis Medstation but “do not have sufficient stock” for the ordered dose. Areport will be generated automatically in pharmacy to refill that medication.

WHEN PHARMACY IS CLOSED, medications may be accessed on another nursing station using “Global Find”. Select the shaded medication. This opens the Review Order screen > select the shaded medication to display the list of profile stations that currently have that medication loaded in a quantity greater than 0. Stations are listed in numeric order, then alphabetical order. Select the desired station > select Send Patient Order > a confirmation message appears indicating that your patient order has been sent to that station > your patient order is accessible at the destination for ONE hour. A COPY OF THE PHYSICIANS ORDER MUST BE PRESENTED TO THE NURSE GRANTING TEMPORARY ACCESS

e. Close each drawer between medication removals. Narcotics, benzodiazepines and controlled agents requirecounting. Verify count as required. Any medication can be modified by Pharmacy to be on a “Blind Count”.This option may be implemented to monitor loss or wastage as needed and will have an effect on all PyxisMedstations containing that specific medication.

f. Verify each medication against the MAR/CMAR for name, dose, time, route of administration and drug allergies. –Always check to match the dose you plan to administer.

g. The nurse checks the patient armband and notes allergies. The nurse prepares each medication foradministration at the patient’s bedside. The nurse administers the medication to the patient. Documentation ofthe MAR/CMAR is made after administration on the patient’s MAR/CMAR at the bedside.

h. Process for medication administration continues until all assigned patients have received their medications.

i. Removal of one-time doses will fall off/disappear from the Medstation screen once it has been removed.

j. One of the following warnings may appear during a removal operation:

Too Early – administration is too early compared to the next scheduled dose

Too Close – Administration is too close to last administered dose

Too Late – Administration is too far from last scheduled dose

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Note Pharmacy enters medications according to standard hospital times as per WRH Policy. If you require a change to an administration time, please notify Pharmacy ASAP.

Narcotics, Benzodiazepines and Controlled Drug Removal

Each user is responsible for maintaining strict control and accuracy in the handling, administration and documentation of narcotics or controlled drugs. Deviation from policy and procedure in handling narcotic or controlled drugs is a serious practice offence.

When accessing a narcotic, benzodiazepine, or a controlled drug, the user must count the medication and enter this number before removal (BLIND COUNT). This is a beginning count.

There will not be shift counts, however a monthly manual count will be conducted on all narcotic, benzodiazepine, and controlled drugs by nursing. A list will be posted on the side of the Pyxis machine and will be signed each month as the inventory count is completed(see appendix D- Pyxis Monthly Manual Narcotic Count ) Each Nursing unit will decide which staff members are responsible for this task.

Restocking Narcotics To replenish additional stock of narcotics, benzodiazepines and controlled drugs to Pyxis: a. The pharmacy technician will log into Pyxis > select required narcotic or C/S to be refilledb. Perform physical count of narcotic being replenished.c. Verify name of drug, strength, expiry, form and amount of drug being replaced.d. Enter amount into Pyxis. The nurse and pharmacy technician will both sign the Pyxis Refill Sheet.

Narcotic Wastages a. Wasted narcotic and controlled drugs must be witnessed by a second nurse and documented in the Pyxis

system by having the nurse enter their ID and password at the time of the removal.b. In the event the waste cannot be recorded at the time of the removal, the nurse is to return to the Pyxis

machine with a witness and document the wastage.c. To waste a medication select waste icon from the main menu and follow directions.d. Pyxis allows you to waste narcotics, benzodiazepines and controlled drugs that have been started on another

unit. Please refer to Pyxis reference guide for further assistance.

Returning Medications “Return” allows you to return medication to the Pyxis if the package/medication is intact. a. Select “Return” icon from the Main Menu.b. Select the patient whose medication is being returned.c. Select medication to be returned from the list of removed medications.d. Select “Return Now”e. Follow prompt to return medication to return bin or original pocket. Place the unopened package in the return

bin or original pocket. Note if item is too large, place in “return to pharmacy” binf. The OR will have a bin located at the side of their Medstation for returning of their narcotics. Narcotic

returns/waste will be put in a Ziploc bag along with the Controlled Drug Administration Record. The numberstamped on this record must be entered into the Pyxis machine at the time of the return.

Narcotic Discrepancies a. The Pyxis Medstation flags all narcotic discrepancies with a discrepancy icon, which is located at the lower

right corner of the main screen. To resolve a discrepancy:- Select “Document Discrepancy” from the Main Menu

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- From the list of undocumented discrepancies, select the discrepancy you are resolving- Select reason for the discrepancy or select “Other” to type an explanation. It is mandatory to enter

an appropriate reason for any discrepancy.b. All nurses are responsible to resolve narcotic discrepancies (inaccurate narcotic counts) at the time of the

occurrence. A witness is required to resolve a discrepancy.c. Complete this process by inventorying this medication : NOTE: This may create another discrepancyd. Any discrepancies that cannot be resolved immediately MUST be resolved before any nurse(s) leave the unit

at the end of their shift.e. Discrepancies resulting in unaccounted for or missing narcotics/benzodiazepines/controlled substances must

be brought to the attention of the Unit Manager immediately. Unit Manager may contact Pharmacy for furtherreports. If unable to resolve, the Nurse Manager must complete and submit a medication incident report (seelink below to Health Canada, Appendix E) to the bureau of Dangerous Drugs within 10 days of discovery.

http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/substancontrol/substan/compli-conform/loss-perte/form_4010-eng.pdf

Miscellaneous

Automatic Stop Orders (ASO’s) a. Automatic stop orders for some medications apply when the physician has not stated in the duration in the

order. If a specific time period has been stated, the order will be processed accordingly.b. Do not continue to override medications without ensuring that a reorder for the medications is obtained.

Inappropriate overrides will be followed up by your unit’s Manager.

“Specialty patients” created by Pharmacy - Pyxis stations may have patients that have been created to:

1. Allow removal of emergency medications during Code situations : “Code Pt” -2. allow the user to access appropriate medications to replenish supplies/carts3. to remove specialty items ex. “Endo key”

Removal of medications under these “patients” will be monitored closely. “Specialty patients” MUST NOT BE USED to remove any medications/items for patients admitted at WRH

Medication Overrides a. Override function allows users to remove first doses for emergency situations or one time Stat medications

when the order has not yet been processed by Pharmacy. A daily Override report will be generated andaudited by Pharmacy. The Nursing unit will be contacted by pharmacy to fax down the order for medicationsremoved. If Pharmacy does not receive this order by the end of the shift, Pharmacy will complete an incidentreport. It is ultimately the responsibility of the RN to have a written order for all medications.

b. During pharmacy hours, the Override function is available for a limited number of medications consideredappropriate for each Pyxis Medstation. If the medication is on the Override list, it may be removed prior toPharmacy processing. .

c. After pharmacy hours, all profiled Pyxis stations will convert to “Critical Override” and all medications withinthe Medstation are available to the user. These orders have not been reviewed by a Pharmacist forpossible allergies or interactions. Use your assessment of the patient’s condition and clinicaljudgment when retrieving any override medication. All transactions are recorded by Pyxis at all times.

d. Always check the physician’s orders to ensure a medication has not been discontinued before overriding.e. Note: Override does not apply to units with NON-PROFILED Pyxis Medstations



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Emergency Downtime Medications in the Pyxis Medstation can still be retrieved if access to Pyxis is not possible for an extended period of time. During a Community disaster or an emergency situation, (i.e. Hospital wide power outage) contact Pharmacy Management. Pharmacy will arrange for Security to deliver an envelope containing the Pyxis keys and a narcotic administration record. They will to the MRP and he/she shall open the back of the machines. WHEN keys are used to open the Medstation, the manual narcotic record provided (see Appendix F) must be used to document all removals. When the Medstation becomes fully functional again, an inventory of all narcotics, benzodiazepines, and controlled substances must be done by two nurses. Once operational, the keys and the narcotic record must be put back in envelope and returned to Pharmacy Management STAT

Recovering a Failed Drawer A failed drawer message may appear during your medication removal. A failed drawer may occur in the instance of overstocking or packages not lying flat. A failed drawer icon will appear on the bottom right corner of your screen a. To recover failed drawers (jammed or overstocked) select “Recover Drawer” from the main menu.b. Check for any items blocking the drawer. Lay all packages flat. Close the drawer.c. Recovery of drawer that contains any controlled substance will require a witness to recover and

perform physical count.d. If unable to recover failed drawer call the Pyxis Help Desk at 1-800-727-6102 for support as necessary. Do

not call Pharmacy.

Adding a Patient

New patients will be admitted through the ADT system as per current practice.

a. If a Patient name does not appear on the screen:1. Patient will be added by selecting “New Patient”2. Enter patient’s last name and first name IN UPPER CASE3. Enter patient’s ID/Account number.

b. Editing Patient Information in the Emergency Room:1. It is the user’s responsibility to ensure that information entered regarding a patient is correct.2. Select the “Patients” icon from the Main Menu3. Select the “Edit Patient” and the patient you wish to update4. Only the patients name can be edited5. Once completed, select the “Save” icon6. Please refer to the Pyxis “Quick Reference Guide” for assistance

PHARMACY DOES REVIEW ACTIVITY ON MANUALLY ADDED PATIENTS

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APPENDIX A: HOSPITAL STAFF-PYXIS ID/PASSWORD ASSIGNMENT

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APPENDIX B: STUDENT NURSES-PYXIS ID/PASSWORD ASSIGNMENT

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APPENDIX C: NURSING INSTRUCTORS-PYXIS ID/PASSWORD ASSIGNMENT

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APPENDIX D: PYXIS MONTHLY MANUAL NARCOTIC COUNT

TO BE DONE ON NIGHT SHIFT THE FIRST DAY OF EVERY MONTH

DATE Completed by RN #1 Completed by RN #2

January 1/yyyy

February 1/yyyy

March 1/yyyy

April 1/yyyy

May 1/yyyy

June 1/yyyy

July 1/yyyy

August 1/yyyy

September 1/yyyy

October 1/yyyy

November 1/yyyy

December 1/yyyy Notify the Charge Nurse, CPM or Program Manager before this sheet ends

TABLE OF CONTENTS Policy/Purpose 1 Procedure 2 · 2018-09-19 · POLICY WRH Universal (WRU)...

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Transcript of TABLE OF CONTENTS Policy/Purpose 1 Procedure 2 · 2018-09-19 · POLICY WRH Universal (WRU)...