Apply common sense to medication security poli

There are a few secrets to writing more practical policies to help save your staff time and still allow you to comply with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Some statements regarding medication safety, for instance, in the JCAHO standards don’t have to be taken so literally.

For example, JCAHO’s medication standard MM.2.20 says hospitals must secure medications so that unauthorized persons cannot access them.

To “secure” medications, the JCAHO wants you to keep all of them in locked containers in a room or under what they call “constant surveillance” if staff do not lock them up. This is a Centers for Medicare & Medicaid Services (CMS) requirement.

However, when writing your policy for this standard, know that locking up all medications is impossible. Keep that in mind when defining what secure means for you, says Bud Pate, BA, REHS, executive consultant for Kaiser Permanente hospitals in Southern California.

Consider the following four tips when writing your policies and procedures on medication security:

Don’t lock down all medications
Access to the pharmacy is usually controlled through a locked door. Once a person is inside, however, noncontrolled medications are stocked on open shelves because staff are there. Extend this same logic to patient care areas.

“It does not mean that somebody has to be assigned to watch the medications,” Pate says.

“A 24-hour Rite Aid is under constant surveillance. There is a check-out person up front to make sure you don’t walk out with the drugs, [but] there aren’t people patrolling the aisles.”

Many medications in the operating room do not need to be stored in locked drawers because they are not controlled drugs. For example, epinephrine falls into the noncontrolled category and thus staff do not need to store it in a locked drawer, Pate says.

Try the policies Fairview Hospital in Cleveland has for medications such as plain intravenous (IV) solutions, like water or saline. The hospital stores them in wire racks in view of nursing staff or secretaries, says pharmacy director Michael Hoying, RPh, MS. If the storage area is not locked, but in view of a staff member, it meets the definition of constant surveillance, he says.

Another tip to help you comply: Adequately staff the materials management department where IV solutions are stored.
In addition, anesthesia carts may be kept unlocked in certain units, such as the delivery area for when physicians must perform an emergency cesarean section and the anesthesiologist is not present, Pate says. As for emergency medications on a crash cart: Don’t lock the cart, although you may want to use a tamper-proof seal on the outside.

Staff at Fairview secure most drugs in operating areas and on anesthesia and medication carts with tamper-proof seals, such as shrink wrap, plastic seals, key or combination locks, or fingerprint recognition.

“In most of our hospital, we consider medications on an anesthesia cart to be under constant surveillance, if they are in an operating or delivery room between cases inside a controlled perioperative or delivery suite,” Pate says.

At Fairview Hospital, the pharmacy provides emergency cesarean kits and secures them because staff stock controlled drugs in the anesthesia carts and Ohio law requires them to be locked, Hoying says. Pharmacy staff should work with nursing staff, physicians, materials management, and other medical staff members involved to determine areas where staff need frequent access to medications.

For example, pharmacists should assess areas where staff need medications and should ask nurses and physicians the medications they need available to do their job, Pate says.

TIP: Needs might vary from unit to unit, Pate says. For example, emergency room staff will need quick access to medications to treat incoming patients. Consider such specialized needs when you sit down as a group to discuss this issue.

Define authorized workers
Many hospitals have struggled to define who is authorized to be in areas with medications, Hoying says. For example, pharmacists are licensed to handle medications in this secure area, and housekeeping staff need access to the pharmacy to clean floors. Even if your pharmacy is open 24 a day hours and someone can monitor access to the pharmacy, your staff need to take precautions.

TIP: Don’t leave controlled drugs out on the counter, Hoying says. At his pharmacy, anywhere from 10–12 people could have access to the drug. Physically hand the drug to the staff member picking it up. Get his or her signature on a form that says he or she received the controlled substance.

Your hospital should list the people it wants authorized to be in the presence of various medications. Decide who should have authorization based on job duties.

For example, authorize housekeepers to be alone with noncontrolled substances between cases in the operating room. Banning housekeeping from operating areas would interfere with the daily operations of the hospital because those areas must be kept clean.

TIP: To help determine who goes on your list make two columns on a page. n one column, list all the workers I who have access to certain areas and those who don’t. Separate them by unit if that helps. Next, in a separate column, comment on how the worker’s access—or lack of it—will affect daily operations, Pate says.

TIP: Educate nonlicensed staff members about the hospital’s medication security policies.

Secure your narcotics
You must keep controlled drugs, such as narcotics, secure to prevent theft. Schedule II substances, such as OxyContin, morphine, and hydromorphone, fall into this category. Fairview Hospital stores some medications in locked areas where people are always present, Hoying says.

However, the facility does not rely on staffing alone. It holds inventory checks and has a specific procedure for identifying missing stock. Read more about how it works below.

Five years ago, someone used a crowbar at Fairview Hospital to break into a controlled stockroom after the staff left for the night, Hoying says.

As a result, if nonauthorized workers can access an area when it’s closed, staff members no longer store drugs there, Hoying says.

However, they will store drugs in areas that close—like Fairview’s oncology clinic—if there is no way for someone to access the area when it is closed, Hoying says.

Fairview’s oncology clinic is separate from inpatient care areas The hospital stores controlled drugs in the oncology department pharmacy because there is no direct access to it during closing hours, he says.

Know your lock codes
The majority of Fairview Hospital’s medication stock on patient units is kept in locked medication rooms, Hoying says. Each room has a punch lock that requires staff to enter a code to gain access.

TIP: Nurses and other authorized staff must learn the access code to medication rooms and keep it confidential. Tell staff not to write the codes on the wall or near the door, and to change the code if you feel unauthorized people have learned it, Hoying says.

Fairview Hospital also stores some medications in automated Pyxis medication storage cabinets. The hospital’s Pyxis units require staff to scan a badge that has their thumbprint on it, Hoying says.

Don’t use Pyxis throughout the organization to store controlled drugs—that would be overkill to meet the requirements, Pate says. Rely on a combination of measures, such as Pyxis, locked rooms, and constant surveillance storage. This works well at Fairview Hospital and meets their financial needs, Hoying says.

Hospitals safely store medications.

• Hospitals stock or store approved medications only.

• Hospitals store medications in conditions that ensure stability.

• Hospitals store controlled substances to prevent theft.

• Hospitals keep all expired, damaged, or contaminated medications separate until they are removed.

• Hospitals keep sound-alike and look-alike drugs separated to prevent confusion.

• Hospitals label the contents, expiration dates, and warnings for all chemicals used in medication preparation.

• Hospitals keep drug concentrations standardized.

• Hospitals remove concentrated electrolytes from patient care areas unless they must be available for treatment or staff members can prevent accidental administration.

• Hospitals keep medications in ready-to-administer forms in patient care areas.

• Hospitals periodically inspect medication storage areas.

Unit: ___________________ Date: ___________________
Time discrepancy noted: ________
Registered nurses counting: ________________________________
________________________________

Nursing section:
What is the discrepancy?

___________________________________________
____________________________
___________________________________________________________
_________________________________________

What was done to locate the source of the discrepancy?
__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________

Pharmacy follow-up notes:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


Source: Fairview Hospital, Cleveland. Reprinted with permission.

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