Instructions for use:
This is a standard operating procedure (SOP) template for nuclear medicine medication
security. This template should be altered, modified, or customized to meet the needs and
particular circumstances of your institution. Consult with appropriate advisors prior to use.
This template is intended to assist you in meeting The Joint Commission (TJC) requirements
in effect as of March 2012. Institutions that use Det Norske Veritas (DNV) or American
Osteopathic Association (AOA) for accreditation prepare their SOPs as appropriate to meet
the relevant standards of their accrediting body.
__________________________________________________________________
NUCLEAR MEDICINE MEDICATION SECURITY TEMPLATE
(Insert Hospital Name, etc.)
Effective date:
_________________
Department:
Nuclear Medicine
Program:
Hospital Accreditation
Chapter:
Medication Management and Environment of Care
Medication Management Standard and
applicable Elements of Performance
MM.03.01.01:
Medication storage is designed to assist in
maintaining medication integrity, promote the
availability of medications when needed, minimize
the risk of medication diversion, and reduce
potential dispensing errors. Law and regulation
and manufacturers’ guidelines further define the
hospital’s approach to medication storage.
Environment of Care Standard and
applicable Element of Performance
EC.02.02.01:
The hospital manages risks related to hazardous
materials and waste.
EP 06 – The hospital minimizes risks associated
with selecting, handling, storing, transporting,
using and disposing of radioactive materials.
EP 03 – The hospital stores all medications and
biologics, including controlled (scheduled)
medications, in a secure area to prevent diversion,
and locked when necessary in accordance with
law and regulation
EP 06 – The hospital prevents unauthorized
individuals from obtaining medications in
accordance with its policy and law and regulation.
i. SCOPE: All clinical staff, radiologists, pharmacy directors, radiation safety officer, nuclear
medicine technologists and security personnel
ii. PURPOSE: To ensure that packages containing radiopharmaceuticals received either during or
after normal working hours are handled in a timely, secure, and safe manner.
iii. POLICY: The receipt of radiopharmaceutical packages either during or after normal working
hours will be performed in accordance with instructions on handling the packages safely and
information on contacting the Radiation Safety Officer in an emergency.
iv. PROCEDURE:
a. The delivery personnel of the contracted radiopharmaceutical services provider(s) will be
furnished with the combination/key/access card to the door of the nuclear medicine Hot Lab.
b. All radiopharmacy personnel making deliveries to the nuclear medicine department will be
identified by employer issued photo identification and shall be trained in this procedure.
c. Upon gaining access to the Hot Lab, delivery personnel will place the package where
indicated. If delivery is made after hours, the delivery personnel will also sign the delivery log
recording the following information: date, time, company and delivery personnel name.
d. The Hot Lab door will be secured after the delivery of the package containing
radiopharmaceuticals.
e. During normal working hours the nuclear medicine technologist will inspect the package to
ensure that it is not wet or damaged in any way. If delivery is made after normal working
hours, the on-call nuclear medicine technologist will be contacted by the delivery personnel if
the package is wet or appears to be damaged in any way. The delivery personnel will remain
in the hospital until it has been determined that neither he nor she has been contaminated.
f.
Nuclear medicine technologist and/or RSO on-call contact numbers:
• (Name, title & contact number)
• (Name, title & contact number)
• (Name, title & contact number)
g. It is the responsibility of the nuclear medicine technologist to notify the radiation safety officer
of any incidents involving receipt of a package containing radiopharmaceuticals that has been
damaged.
h. Radiopharmacy delivery personnel are authorized to access the nuclear medicine Hot Lab in
conformity with existing hospital policy and procedures.
Disclaimer: Any reader of this document is cautioned that Cardinal Health makes no representation,
guarantee, or warranty, expressed or implied as to the accuracy and appropriateness of the information
contained in this document and will bear no responsibility or liability for the results or consequences of
its use.
March 23, 2012