Medication Security - Bedside Medications / Self Administration
Do medications kept at the bedside need to be locked ?
Any examples are for illustrative purposes only.
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.
The requirements will also apply to sample medications, and if permitted by the organization, to medications brought in by a patient or family.
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. The risk assessment 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 proactive 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.
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.
The requirements will also apply to sample medications, and if permitted by the organization, to medications brought in by a patient or family.
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. The risk assessment 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 proactive 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.
Manual:
Hospital and Hospital Clinics
Chapter:
Medication Management MM
First published date: June 19, 2018
This Standards FAQ was first published on this date.
This page was last updated on October 25, 2021
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