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Security Management Systems for Medication Storage, Preparation and Dispensing Areas for UWHC (1.29)

Security Management Systems for Medication Storage, Preparation and Dispensing Areas for UWHC (1.29) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.29





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 1
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.


I. PURPOSE:
A. Establish guidelines to ensure safe and secure medication storage, preparation and
dispensing areas in the University of Wisconsin Hospitals and Clinics (UWHC).
B. Ensure compliance with legal and regulatory requirements pertaining to pharmacies
including narcotic drug security.
C. Establish effective technology systems, physical security and police response systems,
and comprehensive policies with collaboration between UWHC Pharmacy and UWHC
Security leadership groups.

II. POLICY:
A. All medications will be stored and preparation, ordering, and dispensing activities will
occur in locations that are secure and have access limited to authorized personnel.
B. UWHC Pharmacy staff or management will notify UWHC Security, and local law
enforcement for all crimes and significant security incidents, including thefts of funds,
narcotics, or products, burglaries and attempted burglaries, robberies and attempted
robberies and any crimes to persons or property.
C. The Department of Pharmacy security policy will utilize video surveillance, and card
access technology in all pharmacies.
D. Security alarm systems will be in place for all retail pharmacies.
E. Training will be provided to all Pharmacy staff related to security, robbery, and crime
prevention as part of the pharmacy orientation and periodically thereafter.
F. Tests of alarms and security systems and periodic audits will be conducted on a regular
basis with cooperation between UWHC Security and Pharmacy Departments..

III. DEFINITIONS:
A. Authorized Personnel: Authorized personnel are those individuals who in the scope of
their employment or approved activities have need to order, receive, prepare, dispense or
administer medications or who conduct other activities that are essential support
functions in medication areas.
B. Proximity Card Access Systems: Proximity card access systems utilize an employee ID
badge with an embedded proximity device in combination with electronic card reading
technology and door controls to manage entry into secure locations in UWHC. UWHC
utilizes two institution-wide systems (Andover and Pegasys) and one pharmacy specific
systems (ADT). Proximity card access requires entry of data into an access control
computer system for each employee based upon approved level of access. Entry of data
into this server is centralized by the UWHC Security Department for the institution-wide
systems and in the Pharmacy Department for the ADT system.







Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 2
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.

IV. PROCEDURE:
A. Authorized Personnel
1. A conviction check and test for illegal drug use is completed for all new employees
with appropriate follow-up.
a. Staff who do not pass conviction or drug tests will not be allowed access to
medication use areas.
2. All employees will be issued and required to wear the hospital ID badge in
accordance to hospital administrative policy 1.30.
3. Access to medication areas will be limited to authorized personnel.
4. Other personnel may have access to medication areas on a limited basis as required
for support functions such as cleaning, ordering of non-medication supplies and other
specifically described activities but may not handle medications.

B. Proximity Card Access
1. Access to medication areas is granted by UWHC Security only after receiving
approval from authorizing department as follows:

Medication Storage
Area
Authorizing
Department
Staff Requesting Access Access Time
Patient Care Area
Med Rooms (includes
badge access med
drawers)
Pharmacy Non-nursing/RT/MD Staff 24/7
Nursing Nursing Staff
Respiratory
Therapy
RT Staff
Medical Staff
Office
Physicians (including
residents)
Pharmacies Pharmacy All Requests 24/7
OR Med Rooms Pharmacy

Pharmacy Staff
Non-Pharmacy Staff

24/7

Nuclear Pharmacy Pharmacy Non-Nuc Med Staff 24/7
Nuclear
Medicine
Nuclear Medicine Staff 24/7

2. The UWHC Human Resources Department will notify Security of all terminated
employees as they occur. The Security Department will disable access to terminated
employees as notified.
a. Pharmacy will remove terminated pharmacy employees from the ADT proximity
card access system as they occur including access to CII medication storage
cabinets in retail pharmacies





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 3
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.

3. Medical Staff office will notify Security of all terminated physicians (including
resident physicians) and security will disable access as received.
4. Students will only be granted access for duration of educational rotation and will be
deactivated after that time period.
5. On a semi-annual basis the following audits and database corrections will be done.
a. A report will be run by merging security badge access database with the UWHC
Human Resources Department Badge database to provide the following data
elements:
a. Employee Name
b. Employee ID #
c. Department Name and Cost Center (for non UWHC badge users Department
and Source will be provided)
d. Cost Center Supervisor
e. Active/Terminated Status
b. The UWHC Security Department will remove all terminated employees if any are
discovered and Pharmacy will remove any terminated pharmacy employees from
the ADT proximity card access system as they occur including access to CII
medication storage cabinets in retail pharmacies

C. Internet Protocol (IP) Video Surveillance Systems
1. IP video cameras are installed in all pharmacies to allow for surveillance of
medication storage and handling areas. There are also cameras for pharmacy service
windows.
2. The system stores 60 days of images for each camera.
3. The system is used to facilitate investigation of diversions and other events including
crimes.
4. The system is intended also as a deterrent for criminal actions.
5. The cameras are part of an institutional system managed and supported by the UWHC
security department.
6. Access to video images is available to Pharmacy Managers in cooperation with the
Security Department.

D. Security Training
1. All pharmacy staff will complete area specific training at the beginning of
employment and periodically thereafter.
2. Ambulatory pharmacy staff will receive specific training on robbery prevention and
responses.

E. Security Alarm Testing





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 4
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.

1. All security alarms will be tested periodically with cooperation between UWHC
Security and Pharmacy Departments.

F. Central Pharmacy
1. Proximity card access control system (prox-card) is in place to limit access to only
authorized personnel.
2. A service window is available in the “F” elevator lobby for visitors needing service
from central pharmacy.
3. A holdup alarm is in place in the central pharmacy to alert UW Police and UWHC
Security in the event a robbery takes place.


G. Medication Rooms
1. Proximity card access control system (prox-card) is in place to limit access to only
authorized personnel.
2. Exceptions to proximity card access systems include Intensive Care Units (ICUs),
peri-operative and procedure areas where medications are stored in secure locations
under constant supervision.

H. Pharmaceutical Research Center (PRC)
1. PRC drug storage areas C7/101B and C6 /106 will be locked at all times.
2. Proximity card access control system (prox-card) is in place to limit access to only
authorized personnel.

I. Ambulatory Pharmacies
1. Proximity card access control systems are in place in all ambulatory pharmacies to
limit access to only authorized personnel.
2. All ambulatory pharmacies will have intrusion alarm systems that activate after hours
should there be an unauthorized entrance.
a. Alarms will be received by UW Police, UWHC Security and Security Vendor to
implement appropriate response.
3. All ambulatory pharmacies will have holdup alarms.
a. Alarms will be received by UW Police and UW Security to initiate police
response.


J. Schedule II Controlled Substance Medications
1. Schedule II controlled substances are stored in the “Narc Station” system in the
Central Pharmacy.





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 5
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.

a. A narcotic pharmacy technician shall operate the Narc Station during staffed
hours. The central pharmacist will operate the Narc Station system during times a
narcotic pharmacy technician is not on duty.
b. Overhead video cameras will monitor the Narc Station at all times.
2. Schedule II controlled substances are kept in AcuDose cabinets on the inpatient units,
peri-operative and procedure areas.
3. Schedule II controlled substances are kept in locked cabinets in all other storage
locations including clinics and retail pharmacies.
a. Schedule II controlled substances are stored in proximity card controlled access
cabinets. Only retail pharmacy staff will have access to these cabinets.
4. Audits of schedule II controlled substances control systems are performed on an
ongoing basis with results forwarded and reviewed by an appropriate manager.
5. UWHC Clinical Laboratory Department will complete testing of controlled
substances on an ongoing and ad hoc basis to monitor the integrity of product
preparation, dispensing and waste systems as needed.

K. UWHC clinics, treatment areas and procedure rooms.
1. All medications stored in these areas must have adequate locks and limit access to
authorized personnel only.
2. Areas that use controlled substances shall ensure security as outlined in Pharmacy
Policy and Procedure 15.2 Medication Use in Outpatient Care Areas.

L. Operating Rooms (OR)
1. A CSC or AFCH OR technician shall ensure secure use of controlled substances
within the OR area during hours staffed. At The American Center, all controlled
substances are stored in automated dispensing cabinets or carts.
2. The CSC or AFCH OR technician's controlled substance cabinet keys shall be locked
in the Central Pharmacy after hours.
3. After hours and on weekends at CSC or AFCH, a night cabinet shall be used for
stock controlled substances.
4. The night cabinet shall remain locked at all times.
a. Badge access to the night cabinet is configured to limit access to the following:
b. OR Technician
c. OR Pharmacist
d. Charge OR nurse





Effective Date:

September 2002
Pharmacy Policy Manual
Chapter: Administration
Operations Procedure
Manual
Chapter:

Policy #: 1.29

 Original
 Revision 08-16

Page 6
of 6

Title: Security Management Systems for
Medication Storage, Preparation and
Dispensing Areas for UWHC.


M. Security of Keys providing access to secure medication storage areas.
1. Control of keys that allow access to medication storage areas will be maintained by
the Key Watcher system as outlined in Policy1.45 Management of Pharmacy Keys.


V. COORDINATION:
A. AUTHORED BY: Dave Musa, Pharmacy Manager, Business Operations
B. REVIEWED BY: Chris Corrigan, Director of Security
C. COMMITTEE APPROVAL BY: Pharmacy Managers




Approved By: ____________________________
Director of Pharmacy Services

Date: ____________