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Medication Room Audit

by: Luwana Walton, RN

  1. Is the medication room door closed and locked?
  2. Check all floor stock for expiration dates. Floor stock with expiration dates containing a month and year will expire the last day of that month. Example: 06/2018 will expire June 30, 2018 at midnight.
  3. Open floor stock return to the medication room stock is considered infection control and given the F tag F880 Infection Prevention.
  4. The medication room temperature should be maintained at a range of 68-77 degrees Fahrenheit. This range is obtained from manufactures recommendations. A working thermometer should be present. A temperature log for the medication room should be available and complete with daily temperatures documented and information on what interventions should occur, if it is out of range.
  5. The medication refrigerator temperature should be maintained between 36-46 degrees Fahrenheit. This range is obtained from manufactures recommendations. It also should have a working thermometer and temperature log completed with daily temperatures documented and information on what interventions should occur, if it’s out of range. If using a dorm style refrigerator, it is important to keep the freezer compartment frost free, as it will affect the temperature range if ice builds up. A defrosting schedule should be implemented and documentation of the defrosting noted.
  6. Only medications should be stored in the medication refrigerator, no food or staff lunch or drinks.
  7. Medication refrigerator medications are audited for expiration dates.
  • PPD: This product should be stored between 36-46 degrees and protected from light. Vials in use should be open dated and discarded 30 days after first use due to possible oxidation and degradation which may affect potency.
  • Pneumococcal vaccine: single dose vials, store between 36-46 degrees.
  • Influenza virus vaccine: store between 36-46 degrees. Expiration date as recommended by manufacturer.
  • Hepatitis B, Tetanus and Tetanus/ Diphtheria, follow manufacture recommendations.
  1. Temperature excursion: What is that? A temperature excursion is any temperature reading outside the recommended range for that product storage. However, it is the amount of time or cumulative time, out of range that affects the viability of the product. Anytime appropriate storage temperature are in question, contact the products manufacturer for further guidance about whether or not the product can be used.
  2. For some vaccines, the manufacture specifies that once the multi-dose vial has been entered or the rubber stopper punctured, the vaccine must be used with in a certain number of days. This is commonly referred to as the “beyond use date”. After this day the product must be discarded. To know this “beyond use date” this product must have an OPEN DATE written on the product.
  3. Is it acceptable to write the open date and expiration date (the “Beyond Use Date”) of an opened vaccine multi-dose vial on the box rather than the vial, or must it be written on the vial? It is acceptable to put these dates on the packaging; this may help when reviewing inventory. But it is best practice to write these dates on the vials, as it is possible for the vial to be placed in the wrong box.
  4. Are all controlled drugs double locked? Discontinued controlled must be behind a double lock system until destruction occurs by the pharmacist or other system. Disposal methods for controlled medications must involve a secure and safe method to prevent diversion.
  5. Refrigerated controlled drugs must also be under a double lock system. The medication room door can count as one lock and a lock on the refrigerator will count as the second lock. Stat Safe emergency box also has a lock.
  6. Is the medication room cluttered? Is it organized, clean and orderly? Are full sharps stored there instead of the biohazard room?
  7. Are staff personal bags stored in the medication room? This concern falls under mechanisms to minimize opportunity for diversion.

In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked areas under proper temperature controls, and permit only authorized personnel to access to the keys.

Safe medication storage includes the provision for appropriate environment controls. Because many medications can be altered by exposure to improper temperature, light or humidity, it is important that the facility implement procedures that address and monitor the safe storage and handling of medications in accordance with manufacturer’s specifications, State requirements, and standards of practice.