Ensuring a medication room is always ready for survey requires minimal effort but requires constant vigilance.
Starting with security, medication storage areas must be locked when not being accessed by an authorized person. Schedule II-controlled substances must be maintained within a separately locked permanently affixed compartment (double lock requirement).
Proper labeling is also required for proper storage. Facilities must ensure medications and biologicals are properly labeled in accordance with currently accepted professional principles, including expiration dates.
During the survey process, surveyors focus not only on security and the general cleanliness and organization of medication rooms and refrigerators, but also on proper temperature control.
Refrigerators should be kept at a temperature between 20C (360F) and 80C (460F). Temperature should be monitored and tracked in a log book. State regulations govern the frequency of monitoring and tracking. For medications that require storage at room temperature, the recommended range is 150C (590F) to 300C (860F). Room temperature should be periodically monitored.
Multi-dose vials (MDV) to be used for more than one patient, such as vaccines, should be in a centralized medication area. The vial should not enter the patient room. If the MDV enters the patient room, it should be designated for single patient use only.
Unopened MDVs should be discarded according to the manufacturer’s expiration date. Once a MDV is needle-punctured, it should be dated and discarded within 28 days, or shorter in cases where the manufacturer specifies a shorter date.
Insulin pens are meant for single-patient use only and must never be used for more than one person. Facilities should ensure pens are clearly labeled with the patient name and other identifier(s) and stored in a sanitary manner to prevent cross-contamination.
ACTION ITEM: Does your facility have a process for weekly medication storage audits? Are you following through on items that are out of compliance?
