Accreditation

What you need to know about managing sample drugs

Accreditation Connection, December 10, 2004

Pharmaceutical sales representatives are infamous for arriving at your hospital with all sorts of sample drugs. However, those single-sized packets of Zoloft, Lipitor, and even aspirin can get you into trouble with standard MM.2.20 if you don't deal with them properly. Some hospitals store samples in unlocked "help your self drawers" for employee use.

If a JCAHO surveyor stumbles upon such a stash, it could result in a performance improvement request. Your policy is only as good as the staff following it, so educate them regularly on the importance of respecting sample drugs. "Your sample drug policy should address documentation, storage, usage, and auditing of sample inventory," says author Michael R. Hoying, RPh, MS, director of pharmacy at Fairview Hospital in Cleveland, in The Compliance Guide to the JCAHO's Medication Management Standards, published by HCPro, Inc. Hoying says sample drug policies should contain the following elements:

Documentation
*  A physician signs for all samples
*  A pharmaceutical sales representative documents the lot number and expiration date
*  A staff member or pharmaceutical sales representative logs samples by noting drug, strength, quantity per pack, and total number of packs

Storage
*  Staff store drugs in a locked cabinet
*  Approved staff supervise sample drugs at all times
*  Sample drugs are not stored within any pharmacy in the organization

Usage
*  Sample drugs are restricted from inpatients
*  Samples are restricted to the emergency department and outpatient areas
*  Indigent patients may use free samples
*  Sample drugs may be used as trial medications for new therapies
*  Samples may be used to educate physicians in training

Audit inventory
*  Sample drugs are evaluated for expiration monthly
*  Sample drugs expiring within two months are removed and disposed
*  Recalled samples are immediately removed and disposed

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