Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM
Topic: Medication Management – Accessing Medication When the Pharmacy is Closed ^

What are the requirements for accessing medications in organizations that do not provide 24-hour pharmacy services?

Any examples are for illustrative purposes only.

Organizations are expected to have a process in place for providing medications to meet patient needs when pharmacy services are not available. Such a process generally requires non-pharmacist health care professionals to access medication storage areas, such as a designated medication storage area or the pharmacy.  
When non-pharmacist health care professionals are allowed by law or regulation and hospital policies and procedures to obtain medications after the pharmacy is closed, the following occurs:
  • Medications must only be accessed and removed from medication storage areas or pharmacy by trained prescribers and nurses designated by the organization and in accordance with Federal and State law.
  • After-hours access to the pharmacy by non-pharmacists to obtain medications should be minimized and eliminated as much as possible.
  • Use of well-designed night cabinets, after-hours medication carts, and other methods will reduce the need for non-pharmacist staff to enter the pharmacy.
  • Quality control procedures (e.g., an independent second check by another qualified individual, secondary verification technology, such as barcoding, etc.) are to be in place to prevent medication retrieval errors.
  • A qualified pharmacist must be available either on-call or at another location to answer questions or provide medications beyond those accessible to non-pharmacy staff.

^ This FAQ is intended to clarify the requirement found at MM.05.01.13 EP 2 regarding pharmacy access.
 
 
Last updated on April 06, 2023
First Published Date: March 01, 2023