Community Mental Health &
Substance Abuse Services
of St. Joseph County
Psychiatric Services
Medication Storage, Retention, and Disposal
Subject:
Application:
Operating
Procedure
44.07
All Departments
Effective
3/1/96
Reviewed
11/30/04, 1/24/14
Revised
6/5/06, 2/19/08
05/07/11, 12/26/13
Approved
Purpose
CMHSAS-SJC shall assure that pharmaceutical services which meet customer needs are
available and that medications are provided and administered according to accepted current
practice standards and applicable statute which includes the safe storage and destruction of
medications and medical supplies.
Procedure
1.
The nurse/medical assistant shall inspect all drug storage areas monthly. A record of
these inspections is monitored by the Medical Committee to assure that the following
requirements are met.
a.
Disinfectants and drugs for external use shall be stored separately from
internal and injectable drugs.
b.
Drugs requiring special storage conditions to assure stability shall be
properly stored.
d.
Distribution and administration of controlled drugs shall be documented.
e.
Medication shall be stored in locked cabinets.
1)
2)
f.
Medications at each site will be stored in cabinets that are
securely locked. Only medical personnel will have access to
these cabinets.
Injectable medications will be stored in a locked
cabinet/refrigerator as required.
Telephone number of regional poison control centers shall be posted in
all CMHSAS-SJC facilities.
2. Medications which are discontinued or expired shall be disposed of by a nurse/medical
assistant. This will be documented on the sample log along with signature of a witness
for verification of destruction.
a. Medications to be disposed are crushed in a blender, mixed with cat litter and
disposed of in a plastic bag in regular garbage, except for those medications
specifically designated by federal guidelines to be disposed of in the toilet or
Page 1 of 6
Operating Procedure
Subject: 44.07 Psychiatric Services/
Medication Storage, Retention, and Disposal
turned in to the city police stations that maintain an official disposal site for
prescription medications.
3.
Used sharps shall be placed in the labeled sharps containers ("red box") and shall be
stored in a secured location not accessible to customers.
a.
All sharps shall be disposed of according to the infectious waste disposal
procedures.
4.
Medications that have been discontinued by the Psychiatrist may be kept for 90 days in
case the prescriber restarts the medication. This applies to ACT only.
Review Responsibility
This procedure shall be reviewed annually by the Medical Committee.
Attachments:
Medication Room Inspection Report.
Drug Disposal Log.
Sample/PAP Log
Refrigerator Temperature Record
Page 2 of 6
Location:
Date:
Locked Cabinet
Refrigerator
Outdated medications
Correct sample count
Outdated medications
Page 3 of 6
Drug Disposal Log
Date
Drug/dose/# of pills
reason
RN/LPN
1/31/2008 Cogentin 1mg #60
d/c'd j.evans RN
1/31/2008 Artane 2mg #60
d/c'd j.evans RN
1/31/2008 Topamax 25mg #73
d/c'd j.evans RN
1/31/2008 Abilify 20mg #15
j.evans RN
1/31/2008 Risperdal 3mg #14
j.evans RN
1/31/2008 Remeron 15mg #50
j.evans RN
2/21/2008 ativan 1mg #19
d/c'd
g. finch-smith LPN
3/20/2008 seroquel 100mg #5 d/c'd
g.finch-smith LPN
3/20/2008 adderall xr 20 mg #5 d/c'd
gfinch-smith LPN
3-20-08
adderall
adderall#2
20mg
g.finch-smith LPN
3/20/2008 zyprexa 10mg #1
d/c'd
g.finch-smith LPN
3-20-08 ritalin la 20 #7
d/d
g.finch-smith LPN
3-20-08
vistaril 25mg #3
j. g.
Tumminello
finch-smith d/c'd
LPN
3/20/2008 risperdal 0.25 mg # 5
g.finch-smith LPN
3/20/2008 clonidine ).1 mg #20 d/c'd
g.finch-smith LPN
3/20/2008 risperdal 1mg # 5
d/c'd
g.finch-smith LPN
3-20-08
wellbutrin
samples
xl 300mggexpired
# 14
g.finch-smith LPN
3/20/2008 strattera 25samples
mg # 21 expired
g.finch-smith LPN
3/20/2008 symbyax 12/25
samples
mg # 35
expired
g finch-smith
3/20/2008 namenda starter
samples
kits #expired
6
g finch-smith
3/20/2008 paxil cr. 12mg
samples
#112 expired
g.finch -smith LPN
3/20/2008 paxil 25mg samples
# 70
expired
g.finch-smith LPN
Page 4 of 6
Sample/PAP Log
# delivered
30
5
prescriber
m
m
lot #
Date
10/11/2007
10/22/2007
11/7/2007
11/13/2007
11/26/2007
11/27/2007
11/29/2007
7e30065a
12/5/2007
12/12/2007
12/14/2007
12/26/2007
1/2/2008
7e30065a
1/18/2008
2/6/2008
3/3/2008
3/19/2008
3/27/2008
4/2/2008
4/4/2008
4/15/2008
Page 5 of 6
# dispensed
2
4
4
1
2
2
4
3
4
2
4
4
3
6
4
1
client
# left
27
23
19
18
16
14
0
30
26
23
19
17
23
19
15
21
18
12
8
7
prescriber
y
y
y
y
m
y
y
mehta
mehta
yoder
mehta
m
y
y
m
yoder
Refrigerator Temperatures
Jan
Feb
Mar
April
May
June
July
Aug
Sept
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
April
May
June
July
Page 6 of 6
Aug
Sept
Oct
Nov
Dec