Purchasing and Receiving in the Pharmacy

• The Department of Pharmaceutical Services does not consistently require that Pharmacy requisitions have approval or authorization signatures. As a result, the Pharmacy could purchase drugs which have not been authorized by clinical unit managers. In our sample of 35 Pharmacy requisitions, or drug "want list" forms, we found that 19 drug "want lists", or 54 percent, had one or more missing vendor stickers, reorder numbers or National Drug Code (NDC) numbers and six drug "want lists" or 17 percent had missing dates. Significantly, the drug "want list" forms do not require either a readable name or telephone number of the person responsible for completing the requisition or an approval or authorization signature. The Department of Pharmaceutical Services needs to ensure that requisitioned drugs are not purchased in error, by ensuring that drug "want lists" contain complete information and requiring that all requisitions are authorized and signed legibly by an appropriate supervisory staff person.
  
  
• Pharmacy staff who are authorized to create purchase orders use the same computer security system password to access the purchasing system. Consequently, the computerized purchasing system, which holds purchasing records, invoices, and billing is susceptible to unauthorized access. The Department should limit access to the purchasing function by only authorizing specific Pharmacy staff to create purchase orders and by assigning separate passwords to each high level staff person.

Purchasing, Receiving, and Maintaining Pharmaceutical Supplies

The Department of Pharmaceutical Services maintains San Francisco General Hospital pharmaceutical supplies, and purchases and receives drugs for the Inpatient and Outpatient Pharmacies, the nursing units and the outpatient clinics.

Maintaining Drugs in the Inpatient Nursing Units and Outpatient Clinics

Inpatient Nursing Units

Inpatient Pharmacy staff maintain stock drugs and controlled narcotics in the inpatient nursing units. Each inpatient nursing unit has an automated SureMed unit that stores and inventories the nursing unit’s stock drugs and controlled narcotics. The SureMed produces a daily report identifying the levels of stock drugs and narcotics and necessary refills. Inpatient Pharmacy staff restock drugs and controlled narcotics in the SureMed units.

Pharmacy Technicians from the Inpatient Pharmacy stock the SureMed machines under supervision of a Pharmacist. The Pharmacist is responsible for checking that the stocked drugs and narcotics correspond with the SureMed report. The Inpatient Pharmacy provides a printout to the inpatient unit Head Nurse, verifying which drugs were placed into the SureMed.

In the Inpatient Pharmacy, the Pharmacist or Pharmacy Technician assigned to monitor controlled substances will reorder controlled narcotics, and send the controlled narcotics requisition to the Department of Pharmaceutical Services purchasing division. The responsible purchasing division Pharmacy Technician fills out the Drug Enforcement Agency form, under authorization of the Pharmacy Supervisor, and submits the form to the vendor. The Pharmacy purchasing division keeps one copy of the Drug Enforcement Agency form and sends two copies to the vendor.

Department of Pharmaceutical Services storeroom staff receive controlled narcotics packages, matching the delivery against the Drug Enforcement Agency form. Storeroom staff deliver the packages to the Inpatient Pharmacy and the Pharmacist verifies the delivery, including that the package is properly sealed.

Inpatient nursing units also maintain stock drugs outside of the SureMed units. Nursing staff reorder stock drugs from the Main Storeroom on a pre-printed "Drug Floor Stock Order Form". The nursing unit staff may only re-order the pre-printed drugs on the form and may not hand write other drugs on the form. According to the Department of Pharmaceutical Services, the pre-printed drugs are the floor stock approved by the Nurse Manager and Department of Pharmaceutical Services. Requests for floor stock drugs other than those drugs on the pre-printed form require approval by the Nurse Manager.

Outpatient Clinics

The outpatient clinics maintain supplies of non-narcotic stock drugs but do not have automated SureMed units. Outpatient clinic staff maintain their stock drugs and order needed drugs on a "drug want list" from the Pharmacy Storeroom.

The outpatient clinics do not maintain stocks of controlled narcotics but order controlled narcotics for specific patients, subject to a physician’s order. The physician or other qualified provider fills out a triplicate prescription form, and the Outpatient Pharmacy pharmacist fills the narcotic. The Outpatient Pharmacy has two specific supply cabinets containing controlled narcotics and only Pharmacists have access. The Outpatient Pharmacy maintains a narcotics log, showing narcotic usage since January 1997.

Pharmacy Storeroom

The Pharmacy Storeroom is comprised of the receiving, storeroom, purchasing and administration areas. Pharmacy Storeroome staff order and receive all drugs for the Inpatient Pharmacy, Outpatient Pharmacy, and outpatient clinics. The Pharmacy Storeroom is comprised of 13 staff persons, including (1) Pharmacy Supervisor, (5) Pharmacy Helpers, (4) Pharmacy Technicians, (1) Senior Clerk Typist, (1) Clerk, and (1) Senior Account Clerk.

Authorization of Purchase Requests

The Outpatient and Inpatient Pharmacies and the outpatient clinics send requisitions or "drug want lists" to the Department of Pharmaceutical Services purchasing division to order stock drugs. The Pharmacy Supervisor or designee orders pharmaceuticals from the vendors twice daily. According to Department policy, drug requisitions should have the name and strength of the drug, the vendor’s reorder number (the vendor sticker, reorder number of drug NDC number), the date, and the level of stock ("out", "very low", or "low").

We sampled 35 drug "want lists" submitted to the Pharmacy Storeroom between the period May 30, 2002 through July 25, 2002 to ensure that consistent requistioning procedures were followed. The standard drug "want list" form specifically requests that each cost center provide the following information: (1) drug and strength, (2) vendor sticker, reorder number, or drug NDC number, (3) date, and (4) shortage level. The following inconsistencies were found:

• 19 drug "want lists", or 54.3 percent, had one or more missing vendor stickers, reorder numbers, or drug NDC numbers; and
  
  
• Six drug "want lists", or 17.1 percent, had missing dates.

In addition, the drug "want list" form does not require either a readable name or telephone number of the person responsible for completing the requisition or an approval or authorization signature.

To ensure that all drugs requisitioned and purchased are not ordered in error and to prevent unauthorized orders, the Inpatient Pharmacy, Outpatient Pharmacy and clinics should:

• Require that all requisitions are authorized and signed by an appropriate supervisory staff person.
  
  
• Require that all requisitions have a legible name and telephone number of the person responsible for completing the requisition.

Security of Records

All Pharmacy staff who are authorized to create purchase orders use the same computer security system password to access the purchasing system. The computerized purchasing system, which holds purchasing records, invoices, and billing, is susceptible to unauthorized access. Although we did not find incidents of unauthorized access, we believe that a common password for multiple users facilitates entry by unauthorized individuals.

Conclusions

The Department of Pharmaceutical Services needs to strengthen its internal controls over requisitioning and purchasing pharmaceutical supplies.

In our sample of Pharmacy requisitions, or drug "want list" forms, we found that more than 50 percent had one or more missing vendor stickers, reorder numbers or drug NDC numbers and 17 percent had missing dates. Significantly, the drug "want list" forms do not require either a readable name or telephone number of the person responsible for completing the requisition or an approval or authorization signature.

Pharmacy staff who are authorized to create purchase orders use the same computer security system password to access the purchasing system. Consequently, the computerized purchasing system, which holds purchasing records, invoices, and billing is susceptible to unauthorized access.

To ensure that all drugs requisitioned and purchased are not ordered in error and to prevent unauthorized orders, the Inpatient Pharmacy, Outpatient Pharmacy and clinics should have all requisitions authorized and signed by an appropriate supervisory staff person. The name and telephone number of the person responsible for completing the requisition should be present and legible. Also, the Pharmacy should limit access to the purchasing function by only authorizing specific Pharmacy staff to create purchase orders, and by assigning separate passwords to each high level staff person.

Recommendations

The Director of the Department of Pharmaceutical Services should:

Costs and Benefits

Our recommendations would tighten internal controls over the purchasing and receiving cycle and would reduce the risk of loss from waste, theft or fraud.