SNP03-62 Resolving Discrepancies in Automated Drug Delivery System Rev7.2

Policy: Resolving Discrepancies in Policy Number:
Automated Drug Delivery System (ADDS) SNP03-62
Page 1 of 1
Type: Automated Drug Delivery System

Purpose: The purpose of this policy is to ensure all automated drug delivery system
discrepancies are researched and resolved in a timely manner and in accordance
with all state and federal rules and regulations.

1.0 Policy

1.1 All automated drug delivery system(s) authorized users are responsible for
researching, reporting, resolving all discrepancies prior to the end of their
scheduled work shift.

1.2 All discrepancies shall be reported to Skilled Nursing Pharmacy by the facility
Director of Nursing.

1.3 Skilled Nursing Pharmacy will monitor the investigative process for compliance.

1.4 The automated drug delivery system maintains a complete and accurate record of
all users accessing the automated drug delivery system, including all drugs added
to, or removed from, the automated drug delivery system.

1.4.1 C15b Transaction and C2 Control Medication Discrepancy Reports shall
be generated and reviewed daily by the Director of Nursing.

1.4.2 All ADDS data is stored and available for 10 years.

2.0 Procedure

2.1 All discrepancies shall be researched by an automated drug delivery system
authorized user in conjunction with the Director of Nursing.

2.2 Director of Nursing, or designee, shall review generated discrepancy report(s).

2.3 All discrepancies shall be reported to Skilled Nursing Pharmacy by the Director of
Nursing.
2.3.1 Inappropriate access, removal, or loss, from an ADDS should be
investigated and reported to the board of pharmacy within 14 days.
2.3.2 Control substances theft / loss shall also be reported to the DEA online
using Form 106. (www.deadiversion.usdoj.gov)

Prepared by: Flynn Lew Pharm.D. Version 7.2 Effective Date: 07/01/19
Chief Compliance Officer
Approved Date: 05/07/19
Approved by: Ben Mandelbaum
Implementation Date:
Manager Approved and Implemented by:
Implemented: (dates)
Revised: (dates) Approved: (dates) _________05/07/19________________
_______________05/7/19________ _________05/07/19_______________

The information contained in this document is the Confidential and Proprietary property of Skilled Nursing Pharmacy. Do not copy
or distribute without permission from Skilled Nursing Pharmacy.