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Assign point person to monitor OR medication security

Pharmacy Regulation Resource, February 16, 2005

The Centers for Medicare & Medicaid Services (CMS) and now the JCAHO require hospitals to lock medications in the operating room (OR) or keep them under supervision.

JCAHO standard MM.2.20 requires organizations to secure medications in accordance with hospital policy and law so that unauthorized people cannot obtain them. CMS defines secure as being locked or under constant supervision and the JCAHO is aligning its definition with the federal government.

Many people move in and out of the OR all day, placing greater importance on medication security.

Tip: Assign a qualified staff person, such as a certified anesthesia technician, to make sure all OR medications are locked and accounted for, says Lori Griffith, RN, MS, quality coordinator for Blount Memorial Hospital in Maryville, TN.

Also, consider defining who is authorized to access areas such as the OR, where medications need to be stored.

"Because patients, students, maintenance, and housekeeping have access to the OR, it is vital to make sure medications are locked up or supervised at all times," Griffith says.

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