Emergency Kit Procedures for Medication Access in Healthcare Facilities

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In healthcare facilities, proper procedures for accessing emergency kits, including medication orders, usage slips, and prescription protocols, are crucial. The process involves faxing E-kit slips with prescriptions, tracking usage, and maintaining inventory. Strict guidelines for accessing narcotic E-kits are outlined, including DEA regulations and compliance conditions. Non-compliance may result in restrictions on accessing controlled medications. The policy emphasizes the honor system and consequences for not following protocol.


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  1. ARKANSAS EXPANDED EKITS

  2. EMERGENCY KIT PROCEDURES THERE MUST BE AN ORDER FOR ALL MEDS USED FROM THE E-KIT. A charge slip is not an order and the pharmacy does not know to send any remaining quantity. The E-kit slip should be faxed with the prescription so that the E-kit quantity can be deducted from the prescription. NOTE -Any items used from E-boxes, but not accounted for, will be billed to the facility. After faxing, make a copy of the charge slip for your records and then place the original charge slip back into the E-box. 2

  3. NON-CONTROL & IV EKIT If you are using fluids to mix an antibiotic, you will fax in 2 usage slips; one for the items used from the main Ekit and one for the items used from the IV Ekit. A new IV Ekit will be sent out and the entire Ekit replaced. Once per week the entire main Ekit will be changed out. This will occur on a Thursday or Friday, depending on when your facility is scheduled for the weekly change out. This will help ensure that the Ekit is fully stocked going into the weekend. 3

  4. ACCESSING NARCOTIC EKITS The DEA regulations for accessing controlled drug Ekits are under the following 4 conditions: 1. be faxed to the pharmacy. *The E-kit slip should be faxed with the prescription so that the E-kit quantity can be deducted from the prescription. A CII-CV prescription written by the prescriber can 2. written CII prescription and verbally give a 72 hour emergency CII prescription to a pharmacist. The doctor then has 7 days to provide the hard copy of the CII prescription to the pharmacy. The prescriber can call the pharmacy if there is no 4

  5. NARCOTIC EKITS CONT. 3. CIII-CV prescription and verbally give a CIII-CV prescription. The prescriber can call the pharmacy if there is no written 4. prescriber has a designated nurse agent in the facility, the agent can call the prescription in to the pharmacy. If there is no written prescription for CIII-CV, and the After the pharmacy receives the prescription either by fax, electronically or by phone, the controlled drug Ekits may then be accessed. Once a med is taken out, the usage slip is to be filled out and faxed immediately to the pharmacy. A replacement kit will be sent on the next run. 5

  6. NARCOTIC EKIT POLICY The access to the controlled drug EKits will be on the honor system i.e. nursing must comply with one of the 4 conditions listed before removing a controlled medication from the controlled drug EKits. If these conditions are not met before removing a controlled medication from the EKit then pharmacy will notify the Administrator and/or DON to inform them that the honor policy is not being followed. If the practice continues then the NH COO and Nurse Consultants will be notified. Repeated failures to follow this policy may result in the pharmacy being unable to provide controlled medication e-kits to the facility. 6

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