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Emergency Cart - Medication Security

Please clarify the issue related to medication security on emergency carts. Is the use of a breakaway tag that includes a numeric identification number and a defined process to monitor cart integrity considered an acceptable approach to maintaining security of emergency carts strategically located and readily available for use in emergent situations in patient care areas staffed 24/7.

Any examples are for illustrative purposes only.

The Joint Commission requires that medications are stored in a secure manner to prevent tampering, theft or diversion in accordance with law and regulation. Considering the intended nature and use of emergency carts, organizations must balance security with the requirement that emergency medications and their associated supplies are readily available (see MM.03.01.03) when needed.

While organizations are responsible for ensuring the security of the contents of an emergency cart, use of devices (padlocks, etc.) that could create delays or barriers to immediate access to emergency medications and supplies is discouraged and could potentially be interpreted as 'not readily accessible  for use' (see PC.02.01.11). When security devices are used, the intent would be to use an appropriate device that allows the organization to detect tampering while not creating a barrier or delay in the staff's ability to access the emergency supplies contained within the cart. Therefore, use of a breakaway tag with a numeric identification number is acceptable as long as there was a defined process in place to monitor the integrity of the breakaway lock.

It is most helpful for organizations to conduct a risk assessment in order to identify risks associated with various options available for securing emergency cart contents. The results of the risk assessment will enable leaders to make decisions and design processes that best serve the delivery of safe, quality emergency care while maintaining the integrity of emergency medication and supplies. NOTE: Emergency carts containing medication located in departments that are not staffed 24/7 must be secured in a locked location. 
Last updated on April 15, 2020
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM

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