Medication Security - Bedside Medications / Self Administration

Do medications kept at the bedside need to be locked ?

The Joint Commission standards do not prescriptively require medications kept at the bedside to be locked, unless required by law and regulation. Organizations must ensure the medications are secure – meaning - protected from unauthorized access, tampering, theft or diversion. The requirements that address medication security are found in the Medication Management (MM) chapter of the accreditation manual at MM.03.01.01.

When an organization permits patients to self-administer medications, the requirements found at MM.06.01.03 also apply. If the self-administered medications include medications brought in by the patient or family, the requirements found at MM.03.01.05 apply as well. 

Conducting a risk assessment is a helpful way of identifying risks associated with various options under consideration for securing medication. 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.

The introductory section of the Leadership (LD) chapter provides an example of a pro-active risk assessment model that an organization may use. However, this specific approach is not mandated as there are other risk assessment tools available that may better meet the needs of the organization. Examples may include: root cause analysis, failure mode and effect analysis, plan/do/check/act process, etc.; or combinations and variations.

The organization's individual responsible for accreditation readiness has a copy of the manual containing the full text of standards referenced in this FAQ as they are not published on our website.

Last updated on June 19, 2018
Manual: Critical Access Hospital
Chapter: Medication Management MM

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