This section provides guidelines to ensure that each facility has an established process to monitor the expiration dates of drugs, proper storage of drugs, insure proper labeling of drugs, secure the safety of the drugs, and to ensure proper disposal and documentation of drugs.
Use the following steps:
1. Regularly verify that all medications are current, dates have not expired, and sample medications are listed and current.
•Check the expiration date of all medications monthly.
•Maintain a chart of medications with the inspector’s initials and date.
2. Verify that all medications are properly labeled. The labeling should include the following:
•Name of drug.
•Concentration.
•Route of administration (topical, oral, parenteral, etc.).
•Storage information, such as the temperature and light requirements.
3. Keep drugs in a locked cabinet or drawer that is accessible only to authorized office personnel. This includes sample medications.
4. Store internal and external drugs separately to avoid drug administration errors.
5. Maintain medications that require refrigeration at 35° - 46° F or 2 - 8° C. Maintain the freezer at 7° F or -14° C. In addition, perform the following:
•Purchase a thermometer specific for checking temperatures in the refrigerated unit for medications.
•Complete a daily temperature log for each work day with the employee’s initials on the form.
•Ensure varicella is stored at 5° F or -1.5° C.
6. Prepare medications in a clean area such as an area free of body fluids or dirty equipment, such as food trays, urinals, and dirty linen.
7. Store needles and syringes securely in a locked container in an area where patients do not have access.
8. Store all controlled drugs in a securely locked cabinet. Maintain a current inventory on each controlled substance. The physician is ultimately responsible. The DEA must be current.
9. Ensure drugs are only dispensed by the physician and mid-level practitioner. A mid-level practitioner is a medical assistant, a licensed or registered nurse, nurse midwife, nurse practitioner, or physician’s assistant. Physicians dispense drugs to their own patients. Physicians do not sell sample medications.
10. Enter an appropriate record in the patient’s chart referring to those drugs prescribed and dispensed. Also, record sample medications in the patient’s medical record.
11. Make the Poison Center telephone number accessible in a prominent location. The Poison Center can be used for poisoning emergencies, drug consultations, drug interactions, foreign and national drug identification, and other services. You can contact the Poison Center to obtain literature and telephone stickers.