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Stocking Reversal Agents in Non-traditional Areas

Stocking reversal agents in non-traditional patient care areas (e.g. entryways, stairways, cafeterias, etc. ) has garnered increased attention in an effort to expedite care to a possible drug overdose patient. Therefore, what requirements must be considered when medications, such as opioid reversal agents (naloxone, etc), are stocked in non-patient care areas ?

Any examples are for illustrative purposes only.

As with all medications, the security and integrity of such medications must be assured. Therefore, the medications must be stored in a manner to prevent tampering, theft or diversion at all times (see MM.03.01.01).  While The Joint Commission standards do not define what process must be followed to ensure medication security, organizations should consider conducting a risk assessment as a helpful way of identifying risks associated with various options being considered by the organization.   The assessment must include all applicable accreditation, law and regulatory requirements.

A proactive risk assessment examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided. 

Medications must be stored in a manner consistent with the manufacturer's instructions for use to ensure stability. Therefore, a risk assessment should include environmental factors, such as temperature, light exposure, etc., that may impact medication integrity. NOTE - The guidance for storage listed in a package insert must be followed and cannot be superseded by an organization's risk assessment. 

Organizational and medical staff leadership are responsible for determining the type and location of emergency medications and supplies (see MM.03.01.03).  An order is required to administer any medication. In emergent situations, organizations may consider use of protocols, approved by the medical staff and in accordance with MM.04.01.01 EP 15 (deemed surveys), to guide the administration of urgently-needed medications.

Protocols should include pre-established and approved patient assessment criteria in order to provide timely care and services to patients.  The organization needs to define, in writing, who is authorized to administer medication in accordance with law and regulation (MM.06.01.01).  The implementation of a protocol must be documented as an order in the patient's medical record and dated, timed and signed by the practitioner responsible for the care of the patient.  However, the timing of such documentation should not be a barrier to providing timely and necessary care, or other patient safety advances.

Once the organization chooses to treat an individual, they become a patient of the organization. Therefore, a medical record would be required that reflects all care, treatment and services provided in accordance with the requirements found in the Record of Care (RC) chapter of the accreditation manual, law and regulation. 

Education and Training
Each organization determines education, training or competency requirements for those individuals involved in responding to patient emergencies. 

Evaluating Medication Management Systems
Organizations are required to evaluate the effectiveness of their medication management systems (see MM.08.01.01). Therefore, organizations are encouraged to include emergency response processes, that include the safe medication practices, into their performance analysis activities. Such activities should include the collection and analysis of data that allows leadership to identify and implement performance improvement opportunities. 
Manual: Critical Access Hospital
Chapter: Medication Management MM
First published date: December 26, 2019 This Standards FAQ was first published on this date.
This page was last updated on November 30, 2021 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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