STANDARD OPERATING PROCEDURE

VETERINARY HEALTH COMPLEX

Section: Clinical Date of Issue:

Issued By: Pharmacy
Part: Pharmacy Revision #: 2
Revision Date: 11/7/2012
Pages: Board Approval Date: 9/22/2008
4
SOP #: 86

Introduction: The following outlines the standard operating procedures of the NCSU Veterinary Health Complex Pharmacy
Service:

Procedures:

A. General Information About the Veterinary Health Complex Pharmacy

1. Location:
a. Room 2420 Terry Center
2. Hours:
a. Outpatient: 9:00am – 7:00pm M-F, 8:00am-12:00pm Sat.
b. Inpatient: 8:00am – 7:00pm M-F, 8:00am - 12:00pm Sat.
3. Telephone:
a. patient orders 36570, 36571, 36181
b. purchasing info 36572
c. drug information 36198
d. clinician hotline 36196
e. FAX 36571
4. Personnel:
a. Pharmacists: Gigi Davidson, Dan Aber, Sue Fuller, Susan Hanckel, Carol Hoffman, Lauren Geissele
Saturdays: Joan Davidson, Julie Papay
b. Clinical Pharmacy Resident: Mithun Patel
c. Pharmacy Technicians: Donnie Killough, Ben Tapp, Angel Malasca, Amanda McDonald
d. Pharmacy Cashier: Mandy Hicks
e. Inventory Manager: David Provost
5. Privileges:
a. Anyone possessing a legitimate prescription issued by a privileged CVM DVM may obtain items from the
VHC pharmacy for legitimate patients of the VHC.
b. Privilege status is granted by the Associate Dean for Hospital Services and is based on state licensure or
qualification for faculty certificate.

Approved: 9/22/2008
Revised: 6/9/2010
Revised: 11/7/2012
 6. Paperwork:
a. None. All orders electronically submitted through UVIS.
7. Pricing:
a. Outpatient - acquisition cost of drug plus 75% + $5.00.
b. Inpatient - acquisition cost of drug plus 75% markup + $5.00 setup fee
c. Chemotherapy orders – acquisition cost of drug and PhaSeal devices plus + $26.00 setup fee
d. Pricing information available in UVIS under Inventory/Products application
8. Formulary:
a. Drugs may be added to the formulary via the “Request for Formulary Addition” form which is evaluated by
the Pharmacy and Central Supply Committee. Drugs not on the formulary may be requested on an
emergency basis via the “Request for Non-formulary Item” (AKA ‘the green card’). Drugs purchased via
the Green Card must be paid for in entirety by client or service.
9. Drug Distribution:
a. Outpatient prescriptions are filled and labeled and left in pharmacy to be picked up at time of discharge.
b. Inpatient medications are delivered via a unit dose drug distribution system (24hours medication delivered
by pharmacy directly to patient on daily basis M-F and 48 hours delivered on Friday afternoon to cover
weekend.) This inpatient delivery system allows for smaller inventory stores as well as enables client credit
for unused drugs. Each dose is individually labeled with drug name, strength, lot and expiration date to
provide for easy and unequivocal identification of patient medications. Controlled substances are dispensed
from 6 Pyxis drug dispensing machines via pin number and BioID for each operator. Ward stock is
requested via a computerized order entry system.
10. Drug Information:
a. A library is available for reference. Texts may be photocopied on the pharmacy photocopier but may not
leave the pharmacy.
11. AFTER HOURS POLICY
a. The procedure for obtaining drugs when pharmacy is not open is:
1. House officers on emergency duty have access to the pharmacy. The house officer on emergency
will accompany after hours users to pharmacy. The house officer on duty is not to give out keys
(ID badges) under any circumstances. All access to pharmacy is electronically monitored and
recorded. For all drugs removed from pharmacy after hours, orders shall be electronically entered
in UVIS prior to entry into the pharmacy to obtain drugs. In addition to this electronic order in
UVIS, ALL DRUGS TAKEN FOR ANY PATIENT must be recorded on the After Hours Drugs
Taken Log and shall be completed by the house officer entering the pharmacy. This is to ensure an
appropriate audit trail for the North Carolina Board of Pharmacy. Under no circumstances shall
drugs be dispensed for outpatient use to clients after hours except by the Emergency Service
which acts as a veterinary practice.
12. OUTPATIENT PRESCRIPTIONS
a. Note: The Veterinary Health Complex Pharmacy is registered with the North Carolina Board of Pharmacy.
During the hours that a pharmacist is not on the premises, outpatient prescriptions cannot be filled.
Outpatient prescriptions will only be filled for legitimate patients of the VHC with a VHC medical record
number. Drugs to go home with a patient will only be issued by UVIS prescription. Outpatient
prescriptions are to be submitted electronically via the UVIS system. Anything that is purchased from the
pharmacy and is to leave the building must be labeled and dispensed according to legal requirements in this
state. All items picked up from pharmacy must be paid for either at the pharmacy cashier or at the service
cashier prior to pick up in pharmacy.
b. Drugs dispensed shall be labeled with:
1. name, address and telephone number of the facility,

Approved: 9/22/2008
Revised: 6/9/2010
Revised: 11/7/2012
 2. name of the patient
3. animal identification, species
4. date dispensed
5. directions for use
6. name and strength of the drug
7. name of prescribing veterinarian
c. All prescriptions submitted in UVIS must be pinned by DVM clinicians*.
d. Pharmacy will label all child proofed containers to be sent home with clients. Clients may opt for non-
child-proofed containers which are noted on the reverse of the written prescription record.
e. No outpatient prescription medications that have left the Veterinary Teaching Hospital can be returned for
credit. Please refer to the VHC Pharmacy SOP regarding Returned Medications.
f. No prescriptions shall be left in admissions or discharge areas for client pickup. All prescriptions must be
picked up in pharmacy and paid for prior to pickup.
g. No prescription drugs will be dispensed for human use knowingly. Only NCSU-CVM veterinarians with
hospital prescribing privileges (granted by Associate Dean of Hospital Services) may submit prescriptions
at the Veterinary Health Complex Pharmacy.
h. Rabies vaccine will only be dispensed into the hands of a licensed veterinarian.
i. All non-emergency prescriptions for students, staff and faculty will be prioritized by pharmacy personnel
and will be filled only after all other VHC clients have been served.
j. No items will be dispensed for the purpose of resale as this is a violation of the Robinson Patman and
Umstead Acts.
k. Outpatient prescriptions can be mailed to clients by either 2nd Day Federal Express ($15.00) or Overnight
Federal Express ($26.00). Pharmacy will not ship by any other means and is not responsible for failures
due to Federal Express.
13. PET FOOD
a. Pet food may be ordered via the SA Food Orders in the VHC Applications by Clinical Technicians, Service
Receptionists and Pharmacy Personnel. Food ordered will be sent to Pharmacy from Central Supply,
posted to the client bill, and dispensed directly to the client from the pharmacy reception area after
payment.
b. Special food orders must be pre-arranged with the Pharmacy Cashier who will communicate with Central
Supply to facilitate ordering.

14. INPATIENT PRESCRIPTIONS

a. All drug orders for inpatients shall be made via the UVIS prescription request screen expressing drug name,
dose desired, route of administration, frequency of administration as well as all other required UVIS fields.
b. Standing orders (drugs administered at consistent intervals) will be automatically delivered to the patient by
pharmacy personnel on a daily basis (10:00am and 7:00pm) until orders are changed or patient is
discharged.
c. Leftover doses will be picked up and credited by pharmacy if returned no more than 10 days after
discharged.
d. Under no circumstances shall drugs be stashed for future use by other patients as this severely endangers
the quality of drug therapy administered to VHC patients.
e. Inpatient drugs may not be sent home with patients until they are labeled by pharmacy.
f. Medications brought in by clients should be given to pharmacy for proper storage, approval and
distribution while the patient is in hospital.
Approved: 9/22/2008
Revised: 6/9/2010
Revised: 11/7/2012
 g. A detailed policy regarding disposition of medications brought from home is available (VHC SOP # ).
h. Appropriate orders for administering such drugs shall be submitted via UVIS.
i. Pharmacy will store any drugs left by the client and return all remaining drugs to client at time of
discharge.
15. *PINNING PHARMACY ORDERS
a. When drugs are ordered from pharmacy for a patient, the clinician responsible for that order shall check the
entry for accuracy and “sign” the order with their pin number. However, it is recognized that there are
times when it is physically difficult for a clinician to check an entry on a computer screen and enter their
pin. In these instances, when patient care or client convenience necessitates processing of a pharmacy order
before the clinician is available, Clinical Technicians can enter an order using the following steps:
1. Verbal order transcribed onto a COF identified with the patient sticker
2. Drug, dose, route, number of doses or duration, full instructions for administration, number of
refills if any
3. Clinician responsible for order
4. Technician transcribing and entering order
5. Date and time
b. The technician shall enter the order and pin off the order with their own pin number.
c. They must include the name of the clinician who gave the verbal order in the Comments box.
d. The clinician MUST sign the written copy of the order within the next working day.
e. This privilege shall be monitored based on the number of entries a Clinical Technician makes, and the
clinicians responsible for those orders.
f. Clinicians who are found to use this privilege frequently shall be asked to justify their usage to the Hospital
Board.
16. CHEMOTHERAPY ORDERS
a. All preparation of parenteral hazardous drugs shall be performed by properly trained pharmacy personnel
in the Biological Safety Cabinet (hood) located in the pharmacy clean room.
b. Chemotherapy orders will be prepared in batches at 11:30am and 2:30pm. Orders required outside of these
times can be negotiated with pharmacy personnel, however, oncology residents retain primary
responsibility for preparing chemotherapy orders outside of usual business hours.
c. Under no circumstances are antineoplastic agents to be admixed outside of the Biological Safety Cabinet,
or by anyone not trained in proper use of the Biological Safety Cabinet.
17. COMPOUNDED PRESCRIPTIONS
a. Compounded preparations will be prepared only from national compendial standards, peer-reviewed
literature, or utilizing USP <795> , Pharmaceutical Compounding Non-Sterile Preparations, default
standards.
b. Pharmacy will not compound preparations in the absence of established evidence unless benefit to patient
outweighs risk of compound failure.
c. Pharmacy generally requires at least 4 hours notice for compound preparation. Please consult pharmacy for
preparation times prior to prescribing.
d. Pharmacy generally will not reformulate cytotoxic agents for oral use unless benefit to patient outweighs
risk of personnel exposure to cytotoxic agents.
18. CONTROLLED SUBSTANCE ORDERS
a. All controlled substances for inpatient use shall be obtained from the Pyxis Machines.

Approved: 9/22/2008
Revised: 6/9/2010
Revised: 11/7/2012
 b. Until the Controlled Substance Disposition Screens of UVIS are functional, all orders for controlled
substances shall be written on the Patient Flow Sheet/Clinician Order Form or electronically in PICO with
appropriate documentation of administration, waste and witnessing in the UVIS Controlled Substances
Disposition Screens.
c. All controlled substance orders shall be signed/PINed by a licensed DVM.
d. Unopened containers of controlled substances may be returned to the Pyxis Machine for credit but partials
must be wasted in the presence of a witness and documented appropriately on the patient’s Controlled
Substance Disposition Screens of UVIS.
e. Under no circumstances may partial vials of controlled substances be saved or used for another patient.
Multidose vials may only be used on the patient for whom they were originally issued and may not be
transferred from area to area, but must be locked in the narcotic lockbox corresponding to the area where
the animal is housed. Leftover controlled substances will be accounted for and wasted at the end of each
nursing shift.
f. The Emergency Department may dispense a 24 hr supply of controlled substances to patients utilizing the
ER Dispensed Supply in the ER Pyxis machine. Pharmacists will inspect the ER Dispensed Log Book
once weekly.
19. HOW TO USE THE PYXIS MACHINES
a. Only faculty, house officers, technicians and 4th year rotating veterinary students may have access to the
Pyxis Machines. All others may petition the Hospital Board for Pyxis privileges.
b. Once drugs are accessed (as below) from the Pyxis Machines, an electronic order will be sent down to
UVIS to the appropriate clinician for approval.
c. Drugs will be automatically posted to the patient’s bill regardless of approval status.
d. All Pyxis activity is monitored by remote security cameras and images are reviewed daily and stored.
e. All administration and waste in the presence of a witness must be documented electronically in the UVIS
Controlled Substance Disposition Screens.
20. RESEARCH ORDERS
a. Non-emergency research orders will be prioritized after VHC patients orders are filled.
b. No controlled substances will be supplied by pharmacy for research purposes at risk of the VHC losing
DEA registration.
c. Items stocked by the VHC pharmacy will be supplied to researchers as a courtesy utilizing all legally
required order forms and documentation as long as quantities do not deplete VHC stock. Items not stocked
by the VHC pharmacy or orders in excess of what pharmacy can provide should be ordered by
Departmental accountants.
d. Pharmacy will gladly supply availability and pricing information on any item if possible.

Approved: 9/22/2008
Revised: 6/9/2010
Revised: 11/7/2012