/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/pharmacy/,/policies/administrative/uwhc/department-specific/pharmacy/administration/,

/policies/administrative/uwhc/department-specific/pharmacy/administration/143.policy

201608238

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,Pharmacy,Administration

Storage, Handling, Security and Disposition of Medications (1.43)

Storage, Handling, Security and Disposition of Medications (1.43) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.43







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 1
of 10

Title: Storage, Handling, Security and
Disposition of Medications


I. PURPOSE: This policy provides that medications will be stored securely to protect the safety
of patients and the public while allowing appropriate access by authorized personnel.

II. POLICY: The Department of Pharmacy is ultimately responsible for the storage, safe
handling, security and disposition of all medications throughout the organization.

III. DEFINITIONS:
A. “Medications” include any of the following: prescription medications; sample
medications; herbal remedies, vitamins, or nurtriceuticals; over-the-counter
medications; vaccines; diagnostic and contrast agents used on or administered to
persons to diagnose, treat or prevent disease or other abnormal conditions;
radioactive solutions; and any product designated by the FDA as a drug. This
definition does not include enteral nutrition solutions, which are considered food
products, oxygen or other medical gases.
B. “Authorized personnel” includes those individuals authorized by the Department
of Pharmacy to have access to medication storage areas. This includes but is not
limited to members of the medical and pharmacy staff with direct and indirect
patient care responsibilities, select housekeeping, engineering and security staff,
visitors when under the supervision of medical or clinical staff and government
and accreditation representatives performing regulatory activities. See Pharmacy
Policy 1.29 Security Management Systems for Medication Storage, Preparation
and Dispensing Areas for UW Health.
C. “Medication storage areas” include all of the following: emergency drug boxes
and trays, med flight packs, nursing floor stock, pharmacist floor stock, operating
room and procedure area stock and ambulatory or clinic stock. Only approved
medications are routinely stocked or stored. The Drug Product Selection and
Supply Subcommittee (DPSS) is responsible for approving all medication
locations and supplies within UW Health before they are stocked. Medication
storage outside of approved locations is not allowed. See Pharmacy Policy 13.22
Drug Product Selection and Supply Subcommittee.
D. Medication storage areas are considered “secure” when they are staffed and are
actively being used to provide patient care or preparing to receive patients, they
are accessible only to authorized personnel or when the entire area is locked. A
medication is considered secure if unauthorized personnel are prevented from
obtaining access.







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 2
of 10

Title: Storage, Handling, Security and
Disposition of Medications



IV. PROCEDURE:
A. Safe and Secure Storage of Medications
1. Only authorized staff may access medications. See Pharmacy Policy 1.29
Security Management Systems for Medication Storage, Preparation and
Dispensing Areas for UW Health.
2. All medications will be stored in a secure manner so that patients, visitors or
unauthorized persons cannot obtain access to them.
3. Medications are stored according to package recommendations to ensure
stability
4. All schedule II, III, IV and V medications must be maintained either in an
automated dispensing cabinet or locked within a secure area. Storage of
controlled substances is in accordance with applicable state and federal
regulations.
5. All prescription pads and paper will be stored in a secure area to as to prevent
theft by unauthorized persons or staff.
6. The following locations are considered secure locations:
a. Team support areas and other designated medication rooms
b. Medication refrigerators located in the team support areas or
designated medication rooms.
c. Individual patient medication drawers stored in medication rooms
d. Automated dispensing cabinets (AcuDose®)
e. Pharmacy delivery and return bins located within the team support
areas or designated medication rooms.
f. Emergency carts/ kits.
g. Medications at the bedside. Bedside storage of medications will be
limited to those with an MD order and/or those approved as low risk
by the Regulatory, Accreditation and External Reporting Committee.
7. Medication floor/area stock, for all areas will be resupplied by pharmacy
personnel.
a. Only items approved for stock by DPSS will be stocked. See Policy
13.13 Medication Floor-Area Stock for more information.
b. Pharmacy staff will inspect stock locations for outdated medications
and compliance with regulatory standards. See Policy 1.19 Regulatory
Compliance Inspections.
c. Any unapproved stock found in an area will be removed.
d. There may be some areas that, by exception, pharmacy may delegate
the routine stocking and expiration date checking to non-pharmacy







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 3
of 10

Title: Storage, Handling, Security and
Disposition of Medications


personnel but that in all such cases pharmacy is responsible for
developing the restocking and expiration date checking procedures and
will monitor performance of these systems to ensure compliance with
these procedures. Areas with non-pharmacy stocking and expiration
date checking are as follows:
i. Main Operating Room Cart Locations
 Area stock is resupplied and expiration date checking is
completed by OR Personnel.
ii. Ambulatory OR and Procedure Areas
 Area stock is resupplied by OR and Procedure area
staff. Expiration date checking is completed by
pharmacy staff.
iii. Radiology Contrast Supplies
 Contrast medication is resupplied and expiration date
checking is completed by imaging staff.
8. Patients' Own Medications. The use of patient’s own supplies of
medication(s) is discouraged. refer to Hospital Policy 8.17 Administration of
Medications and Pharmacy Policy 3.2 Stored Medications
a. Patients' own medication should be given to the unit pharmacist for
identification and storage
b. Use of personal medication supplies is discouraged and should be
ordered only when an equivalent formulary product is not available.
c. Use of a patient's own medication is permitted based on a physician
order if the following standards are followed:
i. The patient, guardian or the patient's legal representative must
give verbal consent allowing personal medications to be
administered by hospital personnel.
ii. The unit pharmacist must positively identify the patient's
medication for content and integrity, and store the medications
appropriately. If the patient is using an insulin pump for insulin
delivery, the pharmacist is unable to identify the contents of the
pump. The patient is responsible for identifying the insulin
content of the pump to the hospital staff. An order must be
written to continue the use of the patient's own insulin pump
and insulin during hospitalization
iii. For an inpatient, the medication should be stored in the
patient's medication drawer or in an automated dispensing
cabinet if the medication is a schedule II or III controlled







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 4
of 10

Title: Storage, Handling, Security and
Disposition of Medications


substance. The medication will remain in the patient's
medication drawer unless there is a written order for the patient
to self-administer their medication or to store the medication at
bedside. Schedule II and III controlled substances may not be
stored at the patient's bedside.
9. All medications stored within designated secured areas must be clearly labeled
and stored in compliance with the current high-alert medication policy and the
sound-alike-look-alike medication policies (Refer to Pharmacy Policy 13.20
Safety Strategies for Handling Look-Alike Sound-Alike Medications &
Hospital Administrative Policy 8.33 High Alert Medication Administration).
All medications will be delivered with patient specific or manufacturer
labeling.
10. Medication storage at bedside is not permitted unless an order is written to do
so. Medications stored at bedside must be locked or under constant
supervision. Only non-controlled substances may be stored at bedside with a
physician’s order. Controlled substances may not be stored at bedside.
Patients are to alert staff when leaving the room and the medications are to
then be moved into the secure pharmacy area.
a. Heparin and saline flushes may not be stored at bedside or in nurse
servers unless these areas are locked.
b. While reasonable efforts to maintain security of all medications is
expected, the Regulatory Accreditation and External Reporting
Committee has approved an exception list of low risk medications that
may be stored at the bedside without a physician’s order and do not
need to be kept under constant supervision or locked. This approved
“low risk” medication list applies to all patient care settings
(inpatients, clinics, procedure and perioperative areas). The following
medications are considered “low” risk and may be kept at the patient
bedside without a physician order:
i. Sterile water in pour bottles/vials
ii. Normal saline in pour bottles/vials
iii. Desitin cream (zinc oxide)
iv. Carmex lip balm
v. Cepastat lozenges (phenol lozenges)
vi. Artificial tears
vii. Lacrilube
viii. Saline and sterile water “fish” for inhalation
ix. Nystatin powder/cream (when prescribed for the patient)







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 5
of 10

Title: Storage, Handling, Security and
Disposition of Medications


x. Oral care products
xi. Petroleum jelly
xii. All wound and skin creams (e.g. proshield, alovesta,
double/triple antibiotic ointment packets)

11. Concentrated electrolytes, such as 23.4% sodium chloride, are not to be stored
in patient care areas. 3% sodium chloride may be stocked within the
neurosciences intensive care units in patient specific pockets.
12. MultiDose Vials
a. Ampules and single dose vials are single use only and must be
discarded after use.
b. Twice monthly audits will be completed to ensure opened multi-dose
vials are removed from all storage locations at least once every 28
days. See Pharmacy Policy 1.19 Regulatory Compliance Inspections
for more information. Multiple dose vials will be discarded when
empty, when suspected or visible contamination occurs, or when
identified as opened during twice monthly audits.
c. Multi-dose vials will be dispensed to medication storage locations with
a 28 day expiration date. The 28 day expiration date will be updated
during twice monthly audits if the vial is intact.
d. Unopened products that have exceeded their manufacturer expiration
or the identified 28 day expiration date will be removed from active
storage areas.
e. The rubber diaphragm on all vials will be cleansed with alcohol before
inserting a device into the vial. A sterile device will be used each time
a multi-dose vial is accessed.
13. All pour bottles may be used for a single patient case, and then should be
discarded
14. Refrigerated medications. See Pharmacy Policy 1.32 Medication Refrigerator
Audit Policy
a. Medications that require refrigeration are stored in a temperature
controlled environment suitable for maintaining good stability and
ensuring potency of the product through the manufacturers stated shelf
life.
b. Refrigerators for medication storage shall be audited to assure that
temperatures are maintained within an acceptable range
c. Any refrigerated medication found stored outside the appropriate
storage environment should be discarded immediately.







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 6
of 10

Title: Storage, Handling, Security and
Disposition of Medications



B. Safe Handling and Disposition of Medications:
1. Personnel Authorized to Handle and Administer Medications
a. Registered nurses (e.g.; CRNAs, Nurse Practitioners, Clinical Nurse
Specialists, etc)
b. Nursing Assistants if described in their respective position descriptions
c. LPNs as described in their position descriptions
d. Pharmacists, pharmacy interns, residents, pharmacy technicians and
assistants based on their training and position
e. Respiratory Therapists and Respiratory Therapy Technicians as
described in their position descriptions
f. Students, but only under the supervision of a fully qualified individual
in the field
g. Physicians
h. Physician assistants
i. Medical assistants
j. Radiology technologists
k. Occupational therapists and physical therapists
l. Nuclear technologist
m. Self-administration of medications by Inpatients under the supervision
and with a physician order. For more information on self-administered
medications, please refer to Hospital Administrative Policy 8.17
Administration of Medications.
n. Other personnel as determined by the Department of Pharmacy. Only
authorized personnel, in accordance with the hospital policy, law and
regulation have access to medications. See Policy 8.17 Administration
of Medications.
2. Medications received from the pharmacy should be placed in an approved
storage area as soon as possible, not to exceed 30 minutes from the time of
receipt. See Policy 3.2 Stored Medications.
a. Pharmacy delivers scheduled medications in patient specific unit-doses
medication drawers to the unit team support areas once daily. As new
orders are processed, deliveries of those medications are made via
delivery rounds directly to the medication delivery bin in the secured
designated medication storage area or to the unit via the pneumatic
tube system.
b. Medications delivered via the pneumatic tube system are placed in the
medication delivery bin within the secured designated medication







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 7
of 10

Title: Storage, Handling, Security and
Disposition of Medications


storage area as soon as possible, not to exceed 30 minutes from the
time of receipt.
c. Access to medications in the delivery bin is limited to pharmacists,
pharmacy technicians and nursing staff. The following medications
should not be removed prior to a pharmacist check: chemotherapy
agents, hazardous medications and total enteral nutrition admixtures.
d. As needed medications (PRN) and selected first doses are obtained
from the unit based controlled dispensing cabinets by selection of the
patient from the census screen. The patient profile, as processed by the
pharmacist, displays on the cabinet for dispense. Only one
administration should be made from each dispense.
i. Only certain medications, as approved by the Pharmacy and
Therapeutics committee, may be removed from dispensing
cabinets prior to pharmacist review. See Policy 14.4 AcuDose
Rx Controlled Access cabinets.
3. All medications removed from secure medication storage areas must be
removed just prior to administration and only for one patient at a time. Once
removed from secure medication storage areas, the medication must remain
with the individual at all times and must not be left unattended. To preserve
medication integrity, if not administered or used the medication should be
returned to the original storage area as soon as possible.
4. Nursing and Pharmacy Department personnel follow the policies and
procedures for automated dispensing machines to ensure the safe and
accurate dispensing of medications, accountability of controlled substances
and other medications, accurate patient billing, medication security and to
ensure compliance with state and federal rules and regulations. See
Pharmacy Policy and Procedures Manual Section 14 AcuDose.
5. To ensure safe and accurate administration of medications to patients, a
pharmacist reviews all non-emergent inpatient medication orders against the
medication profile prior to medication dispensing and administration, unless
the absolute necessity of patient clinical needs or safety does not permit
such a review. Nurses and physicians are responsible for judging whether
the patient's clinical condition warrants bypassing the pharmacist review.
For more information on administration of medications, please see Nursing
Policy 10.19 Medication Administration and Patient Care Policy 8.16
Patient Care Orders.







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 8
of 10

Title: Storage, Handling, Security and
Disposition of Medications


6. Pharmacist order review prior to administration is not required in settings
where a physician controls the ordering, preparation and administration of
the medication.
a. In radiology, where pharmacists are not present, designated health care
personnel, as defined by the department of radiology, will control the
ordering, preparation and administration of all IV contrast. No
prospective or retrospective pharmacy review for inpatient orders for
IV or oral contrast is required.
b. The scope of radiology services is defined by the department of
radiology. Designated health care personnel will directly supervise
patients before and after contrast is administered, so that personnel can
intervene in a timely manner in the event of a patient emergency.
c. All policies, protocols and guidelines related to the administration of
contrast media are developed in collaboration with the radiology and
pharmacy departments, and are approved by the P&T committee prior
to implementation.
7. Storage of medication prior to return to pharmacy:
a. Medications that will not be used on a specific patient should not be
stored on the patient care unit, but should be returned to the AcuDose
cabinet or returned to the pharmacy for crediting.
b. Medications identified as belonging to a patient via the pharmacy label
should be placed in the Pharmacy return bin located in the team
support area.
c. Storage of medications to be returned to pharmacy in any other
location is not allowed.
d. Medications that are discontinued or recalled should be returned to the
pharmacy for crediting.
e. Expired, damaged, and/or contaminated medications are segregated
until they are removed from the hospital.
8. The Pharmacy Director is responsible for the proper safeguarding of
controlled substances within the hospital, and oversees the purchase,
storage, accountability, proper dispensing and disposal of controlled
substances. All applicable state and federal laws governing the handling of
controlled substances are enforced. See related pharmacy and hospital
policies for additional information, including Hospital Policy on Narcotic
Control Systems in Patient Care Areas.
9. Medication Disposal or Waste:
a. Intact medications:







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 9
of 10

Title: Storage, Handling, Security and
Disposition of Medications


i. Medications removed from AcuDose that are intact and in
their original tamper-proof package and suitable for use for
another patient must be returned to AcuDose. This ensures that
the patient receives credit for drugs not administered to them.
If the medication is a controlled substance, two licensed nurses
must witness the return and document this in the cabinet.
ii. All medications returned to the cabinet must be placed in the
return bin located in the bottom drawer of the cabinet. The
central pharmacy will manage all returns and process them
according to their subsequent usability.
iii. No uncapped or manipulated needles should be placed in the
Return Bin, instead place them in a needle disposal box, and
then waste the medication solution and syringe in the
Hazardous Substance Waste Container.
iv. Defective dosage forms should be returned to pharmacy via the
Return Bin in a zip-locked bag with a note attached describing
the problem.
v. Medications dispensed from patient medication cassette
drawers that are intact and not used (or refused) by the patient
should be promptly returned to the patient's cassette drawer and
the eMAR should properly indicate that the dose was omitted.
b. Medications that must be wasted:
i. Any product that has come in contact with a patient should be
wasted in a Hazardous Substance Waste Container, not in a
needle box and not in the pharmacy return bin. See Hospital
Policy 8.17 Administration of Medications. See also Pharmacy
Policy 1.31 Handling and Disposal of Hazardous Drugs in the
Pharmacy Areas.
ii. All controlled substances removed from their original tamper-
proof package or protective plastic over-wrap, and/or not
suitable for use with another patient must be wasted and
documented as wasted by two licensed nurses/practitioners.
Such doses should not be returned to the AcuDose cabinet or to
Pharmacy. The dose actually administered to the patient must
be documented on the eMAR, but waste should only be
documented in AcuDose or on the appropriate controlled
substance proof-of-use record in areas without AcuDose.







Effective Date:
Jan 2008


Chapter: Administrative

Chapter:

Policy or Procedure:
1.43

Revision 08/2016

Page 10
of 10

Title: Storage, Handling, Security and
Disposition of Medications


iii. Every fentanyl patch application must have a witnessed
disposal; regardless of the amount of time the patch was
adhered to the patient. This includes patches that have been
applied to the patient for a full 72 hours. Two licensed
nurses/practitioners must witness and document the disposal of
used or partially used fentanyl patches. See Hospital Policy on
Narcotic Control Systems in Patient Care Areas for more
information.
iv. Drug products shall be discarded at such time when the quality
of the product can not be ascertained. Drugs will not be used if
they have not been stored properly or have passed the
expiration date.
v. Pharmacy staff will conduct unit inspections of medication
storage areas to check for expiration dates and assess
appropriate storage conditions and security of all medications.
See Pharmacy Policy 1.19 Monthly Regulatory Compliance
Inspections.
vi. Areas with storage systems (ED, Radiology, Cath etc) will
return all expired medications to the pharmacy department for
proper disposal.

III. REFERENCES AND RELATED POLICIES, PROCEDURES
There are many policies and procedures that are designed to ensure the safe storage, handling,
security and disposition of all medications throughout the organization. Please refer to specific
pharmacy and hospital administrative policies referenced throughout this policy for more
information.

IV. COORDINATION:
E. AUTHORED BY: Michelle Thoma, PharmD
F. REVIEWED BY: Steve Rough, MS, RPh
G. COMMITTEE APPROVAL BY: PPIRC





Approved By: ____________________________



Date: ____________