INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES

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1 HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER MEDICATIONS EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE For all faculty and staff to have accurate information and guidelines to promote safe, effective medication practice in order to provide excellence in caring for our patients. DEFINITION CAMH = Comprehensive Accreditation Manual for Hospitals CAMAC = Comprehensive Accreditation Manual for Ambulatory Care EC = Environment of Care IC = Surveillance, Prevention, and Control of Infection TX = Care of Patients NFPA = National Fire Protection Association OSHA = Occupational Safety and Health Administration USFDA = U.S. Food and Drug Administration RESPONSIBILITY CROSS REFERENCES POLICY All Medications throughout the Medical Center must be procured, stored, administered monitored and disposed of according to Federal, State, Local guidelines and laws as well as standards of accrediting institutions. This is carried out by all faculty and staff who order, dispense and administer medications to patients. PROCEDURE Specific Information: Category Standard Regulation A. General Medication Storage All medications are stored in designated areas to ensure proper sanitation, temperature, light, moisture control, segregation, and security. Pharmacy Policy and Procedure Manual 1. Medication are secured at all times cabinets, carts, medication rooms storing AS Storage of Medications in the Pharmacy AS Medication Standards Page 1 of 1

2 B. Multiple Dose / Single Dose Vials / Containers prescription medications, etc. are locked at all times and inaccessible by nonauthorized staff. 2. Medication storage is separate from nonmedications (i.e., supplies and equipment). 3. External and internal medications are stored in separate areas. 4. Medication storage/ preparation areas are clean. 5. No medications are expired. 6. Any medication owned by the patient must be stored with the patient s name attached to the package. Multiple Dose vials contain preservatives to make extended use possible. 1. Multiple dose injectable vials (for IM, IV, SC, IT use) are dated with the date opened. 2. All multiple dose vials are discarded thirty days after date opened. 3. Single use vials / containers are discarded immediately after a single use. Area Inspection Tennessee Pharmacy Law Safety Policy Manual SA Storage Standards AS Sterile Product Compounding AS Pharmacy Infection Control System System C. Refrigerated Medication Storage Medications requiring refrigeration are stored in Medication Only refrigerators. Non-medications are not stored in a Medication Department of Pharmacy Policy and Procedure Manual AS Standards Page 2 of 2

Medication storage/ preparation areas are clean. 5. No medications are expired. 6. Any medication owned by the patient must be stored with the patient s name attached to the package.

3 Refrigerator. 1. Proper temperature for refrigerated medication is 35 degrees to 46 degrees Fahrenheit or 2 degrees to 8 degrees Centigrade. 2. A thermometer is in place in each medication refrigerator and freezer (if medications are stored in the freezer). Storage of Medications in the Pharmacy AS Medication Area Inspection CAMH TX.3.5 Tennessee Pharmacy Law A daily log is maintained for each refrigerator and freezer indicating a check of proper temperature. 4. Pharmacy and Plant Services (Building Maintenance for offsite clinics) is called immediately if refrigerator temperatures are not within the proper range. 5. An after-hours temperature monitoring system is in place and checked daily for any area that is not open 24 hours / day, 7 days / week. D. Controlled Substance Storage 1. All controlled substances are secured in an automated dispensing unit OR behind two locks. 2. All Controlled Substance administration and wastage is documented to completion on the Controlled Drug Administration Record or in the automated dispensing device. 3. The Pharmacy and VUPD are to be notified if controlled substances are missing. 4. CII Prescription pads (red pads Policy and Procedure and Manual AS Narcotics & Controlled Drugs CL Controlled Substance Administration and Accountability Standards Page 3 of 3

Storage of Medications in the Pharmacy AS 201420-70.10 Medication Area Inspection CAMH TX.3.5 Tennessee Pharmacy Law 1140-04.03 3.

4 E. Sample Medication Storage / Dispensing F. Emergency Medication Carts / Emergency Kits issued by the pharmacy) are in possession of the prescribing physician at all times. 5. All other prescription pads are secured at all times and not accessible to unauthorized persons. 1. Samples are not stored in any inpatient unit. 2. All prescription samples stored in a clinic are secured at all times. 3. Samples are labeled when dispensed using the preprinted sample label. This label is completed without abbreviations. 1. All emergency medication carts are secured with serial numbered locks issued by the Pharmacy. 2. Emergency medication carts are checked daily and documented to verify lock is not broken and the medicti0ons are not expired. 3. Any other serial locks securing medications (Inpatient only) are distributed by Pharmacy. 4. No serial locks are utilized in an offsite VMG clinic for medication storage. Tennessee Pharmacy Law AS Emergency Drugs CL Checking Emergency Carts, Monitor Defibrillators, and Supplemental Emergency Boxes, TX G. Handling of Cytotoxic Drugs All cytotoxic drugs are labeled as such and require safe handling procedures. Only qualified personnel will handle cytotoxic drugs. 1. Any location administering chemotherapy has a Chemo Spill Kit on hand (distributed by Pharmacy) AS Oncology Pharmacy CL Cytotoxic Drug Standards Page 4 of 4

All prescription samples stored in a clinic are secured at all times. 3. Samples are labeled when dispensed using the preprinted sample label. This label is completed without abbreviations. 1.

5 H. Inspection of Medication Storage Areas I. Return of Medication to the Pharmacy 2. Cytotoxic waste is handled as hazardous waste. Trace contaminated cytotoxic drug waste includes items used to prepare drugs and / or clean areas and waste from patient rooms where drug is administered (empty bags, vials, IV tubing, etc.) These items are placed in a container within the patient room or infusion area for cytotoxic waste prior to transport for disposal. Bulk contaminated cytotoxic drugs waste (unused IVs and vials of drugs) is returned to the Pharmacy for disposal. NOTE: See Sharps section for needle Stock is inspected by the Department of Pharmacy on a monthly basis. Off-site clinic staff performs monthly checks and report findings to the Pharmacy. 1. Areas maintain copies of past Pharmacy Unit Inspections including Corrective Action Taken when an infraction occurs. 2. A pharmacist or designee performs an annual confirmation in off-site clinics. Out of date: Any out of date medication is taken to the Pharmacy for proper disposal. Off-site clinics dispose of outdated drugs in a Sharps Container or Biohazard Bag (Red (Chemotherapy) Administration & Management Safety Policy Manual SA Hazardous Material Spill SA Handling of Cytotoxic Drugs SA Waste Disposal, EC.1.3 AS Sterile Product Compounding Systems Tennessee Pharmacy law AS Disposition of Out of Date, Discontinued, or Standards Page 5 of 5

) These items are placed in a container within the patient room or infusion area for cytotoxic waste prior to transport for disposal.

6 Bag) and document on the Medication Disposal Log with signatures of two licensed staff. Unused Medication: Any drug not needed for a specific patient or is not intended for stock is returned to the Pharmacy for proper disposal and possible credit to the patient or unit. Proper patient identification must be included with the medication. Inappropriately Labeled Medications Systems Tennessee Pharmacy law FORMS Edocs EQUIPMENT REFERENCES APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 6 of 6

possible credit to the patient or unit. Proper patient identification must be included with the medication.

CHAPTER 61-03-02 CONSULTING PHARMACIST REGULATIONS FOR LONG-TERM CARE FACILITIES (SKILLED, INTERMEDIATE, AND BASIC CARE)

CHAPTER 61-03-02 CONSULTING PHARMACIST REGULATIONS FOR LONG-TERM CARE FACILITIES (SKILLED, INTERMEDIATE, AND BASIC CARE) Section 61-03-02-01 Definitions 61-03-02-02 Absence of Provider or Consulting Pharmacist