DQA Publication P-01744 Medication Cart Storage: Secured and Locked

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Division of Quality Assurance: Notifications & Updates

Attn:  Hospitals

DQA Publication P-01744
Medication Cart Storage:  Secured and Locked

DQA Publication P-01744, Medication Cart Storage:  Secured and Locked, provides hospital staff guidance related to locking and securing medications.

Having a secure area means that drugs and biologicals are stored in a manner that would prevent unmonitored access to unauthorized individuals. All controlled substances must be locked. Medication automated distribution units with security features, such as logon and password or biometric identification, are considered to be locked. There is some flexibility in the storage of non-controlled drugs and biologicals when delivering care to patients, and in the safeguarding of drugs and biologicals to prevent tampering or diversion. If  a patient care unit is not staffed, or staff is not actively providing care around the clock, controlled and non-controlled substances are expected to be locked. 

If there is evidence of tampering or diversion, or if medication security becomes a problem, hospitals are expected to evaluate their current medication control policies and procedures, and implement systems and processes that ensure the problem is corrected, and that the health and safety of the patients are maintained. The use of breakaway locks, exchangeable trays with sealed plastic, and other tamper-proof devices are valuable tools to alert staff if medication carts have been tampered with, however, these devices do not ensure secured medications.