Medication Management (Pharmacy) Policy and Accountability
The following is an overview of the Medication Management System. Specific policies follow in this section of the manual. It is important to note that this organization does note dispense medications for patients to take at home.
The ordering, administrating and dispensing of drugs shall be performed only by an appropriately licensed person, in
compliance with applicable laws and regulations. Medications are prescribed that are within the scope of service of the
organization. A list of medications for administration and or dispensing (including strength and dosage form) is maintained and readily available. This list is reviewed at least annually.
Additionally, should the organization require to obtain medication to be utilized that is not on the organization's
list, the Medical Director must approve of this request and sign off on minutes documenting the request and approval.
Should the organization confront a medication shortage or outage; either due to a back order, manufacturer's recall, or
a disaster, the Medical Director will be informed and he/she will advise regarding substitution of that medication.
The Medical Director shall be responsible for the safe, orderly and lawful provision of medication services.
Look alike Sound alike Drugs:
Initially a list of look alike sound alike medications/drugs utilized in the organization will be compiled. Action will
be taken to prevent errors involving the interchange of these drugs; e.g., stored in separate areas, additionally labeling
or warning sign added to the container. When the organization adds a new medication/drug; it will be compared to this list for any look alike or sound alike possibilities. If it falls into this category it will be added to the list. Additionally, annually a review will be conducted of this list to prevent errors involving the interchange of these medications/drugs.
Because our facility only offers a limited amount of procedures, for a specific population, with a limited amount of ailments we only require a limited amount of medications. We therefore will make every effort to reduce the amount of superfluous and redundant medications within the facility. This is especially important regarding look alike sound alike medications. Effort will be made to avoid look alike sound alike drugs in this facility. If we encounter a medication that is necessary for the safety and function of our office that is a look alike sound alike to another medication we store, then every reasonable effort will be made to limit errors and mistakes. This will include physical separation from the other medication and clear labeling. Staff members who use the medication will be instructed, informed and educated as to the difference of the medications, the difference in packaging, the difference in mechanism of action, the symptoms of an improper administration and how manage such a situation. Only licensed independent practitioners are allowed to administer medications in our practice.
All drugs administered shall be recorded on the patient's chart with all pertinent information.
All narcotics shall be administered in accordance with all provisions of the law, and entered into the narcotic log with
all necessary information. If any narcotic is given which results in a residual amount being left over, the residual
narcotic must be destroyed/wasted with an RN or an MD witness. The amount of the medication wasted will be recorded on narcotic log, along with the signatures of those verifying waste.
The person administering the medication will withdraw the vial and draw up the specified amount, verifying the order of
the surgeon as to medication, strength, and dosage. The vial will be compared with the syringe and with the surgeon's
order to double check the accuracy of the medication before administration. Please see MP.7: Medication Administration
and Medication Errors.
Storage of all Medications: Please see MP.11: Storage of
All records (DEA 222's, narcotic logs, etc.) that document the purchase and inventory chain of custody of controlled substances shall be maintained for a period of ten (10) years, or for the period required by State or Federal law.
At the beginning and the end of each surgical day, or at another specified interval, controlled substances will be inventoried by two (2) licensed personnel and the results entered in the narcotic log. In the event that two licensed personnel are not available, a responsible clinical staff member will witness the inventory and countersign the narcotic log. The count is a physical accounting of every capsule, tablet, ampule and vial by sight and touch, if necessary. Any unresolved discrepancies in the inventory will be reported to the Medical Director immediately.
All controlled substances needing to be destroyed will be done according to State Law. Permission may be granted for
destruction on site if the amount to be destroyed is not excessive. All paperwork will be completed according to State regulations, including the witnessing of the destruction and signatures of (2) licensed individuals.
We do not dispense drugs to be taken home by patients.
All drugs will be stored in an area which is secure.
All drugs to be added to inventory will be ordered by an
MD. Packages containing drugs will remain sealed until
opened and inventoried by an MD. Narcotics will
additionally be entered into the narcotics log and added to
the inventory totals before being locked up in accordance
with the above. All entries into the narcotics log will be
On a monthly basis, any drugs on site (samples, opened
multi-use vials or inventoried stock, including crash cart
and controlled substances) will be inspected for current
expiration date. Outdated drugs (other than narcotics) will
be discarded using appropriate methods. The Medical Director
may direct an audit of any and all records that are pertinent
to drug prescribing, administration, inventory control, and
Multi-dose vials will be used as appropriate and efficient. Such vials meet certain standards formulated by the United
States Pharmacopoeia to ensure product effectiveness for its shelf life. Due to infection control issues, Multidose vials
should be sized appropriate to the projected use of the product and preferably only used for a single individual
patient. However if the product is not available in single dose vials, appropriate technique (using only sterile needles
and syringes) should be used when withdrawing the product; exposure to air should be minimized to avoid degradation.
Unless otherwise specified by the manufacturer, upon opening the multi-dose vial, the vial will be dated with an
expiration date which is 28 days after opening the medication. Any multi-dose vial/container, which upon visual
inspection exhibits any change in clarity or color, or exhibits particulate matter; do not use the product.
Discard or return to pharmacy immediately.
The organization strives to counsel and educate the patient regarding effective and safe use of medications with written and verbal instructions.
Annually or sooner if indicated the organization reviews its medication management policy and system to evaluate its
medication management system for safety, review any new technology available to the organization, and analysis any
pertinent external data.
1. The clinical staff member will review the policies related to the handling of all pharmaceutical supplies
and assure compliance with all local, State and Federal regulations.
2. Qualified clinical personnel shall be responsible for the stocking, storage and accountability of all
3. All medications and biological supplies shall be clearly labeled with name, strength, quantity, and expiration
date. Cautionary information, if any, should be included on the label. Multiple-use vials are destroyed after 28 days or if upon inspection, particulate matter is noted, cloudiness of contents or the seal on the vial is damaged.
4. Drugs requiring special storage conditions to assure stability are properly stored: drugs requiring
refrigeration or freezing are kept in the appropriate storage environment, dedicated to biologicals.
Please see MP.5: Monitoring the temperature of the Refrigerator.
5. Antiseptics, topicals and other drugs for external use, and disinfectants should be stored separately from
ingestible and injectable medications. On a monthly basis, all inventoried drugs will be inspected for current expiration date. All expired drugs will be destroyed and discarded or returned to a licensed pharmaceutical return company.
6. Storage of Medications, please see: MP.11 Area for
Storage of Medications.
7. Medications may be administered, i.e given to the
patient while the patient is in the facility, only by
order of a Staff member with current medical staff
privileges. Please see MP. 8: Medication Ordering.
8. Medication Preparation, please see: MP.8
9. Anesthesia drug preparation and administration is the
responsibility of the anesthesia provider. For further
information please see Medication Preparation: MP.8
10. Adverse Drug Reactions and Procedures, please see: MP.10
11. Medication Errors and Procedures, please see MP.7
Medications from home, brought to the facility by the
patient, will be handled in one of two methods:
1. The medication will be sent home with the patient's
caregiver or other person accompanying the patient to the
2. The medication will be sealed into a bag, labeled with
the name of the medication, and the patient's name and
stored with the patient's other belongings.
Medications are allowed to be brought in to the organization
from outside the organization by Licensed Independent
Medications may be brought into the organization only when
the Medical Director has full knowledge of this practice and
the medications that are brought into the facility are
directly used in patient care.
These medications must be examined by staff within the
organization and verified that the medication is intact and
has not expired. The LIP must complete a form that will list
what medications that this individual is bringing into the
facility, whether they will be stored in the facility or
removed from the facility, if stored where and how they will
be stored in the facility and the designated use for the
medication. All documentation will remain on site.
Emergency or Crash Cart medication policies, please see Crash
Cart and Crash Cart Security in this volume.
See the 'CONTROLLED SUBSTANCE forms.
See also the 'PHARMACY CONSULTANT CONTRACT' and 'PHARMACY
Approved By Governing Board