LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.14 Medication Storage
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Review and Approved by:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, MD, Chief Medical Officer, on July 5, 2022
I.  PURPOSE
 
Establishes procedures in the Los Angeles County Department of Mental Health (DMH) for medications stored in directly operated clinics including sample medications and client's own medications.
 
II.  DEFINITIONS
 
Sample Medication: Medication provided by pharmaceutical sales representatives at no cost to DMH.

Client's Own Medication: Medication dispensed by retail pharmacies delivered to a DMH directly operated clinic for a specific client.
 
III.  POLICY
 
The Chief of Pharmacy shall approve the list of all medications stored within each DMH directly operated secured medication room.

Medications shall be stored in a locked and secured area, not accessible to clients or unauthorized staff per DMH Policy 352.12 Medication Security.

Test reagents, germicides, disinfectants, and other household substances shall be stored separately from medications and outside medication rooms.

Medications shall not be stored in the same refrigerator with food, beverages, or urine specimens.

Medications shall be stored according to the manufacturer's recommendation.

Medications with containers which are cracked, soiled, or without secure closures shall not be used.
 
Medications shall be stored and clearly labeled in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding.
 
Internal use medications in liquid, tablet, capsule, or powder form shall be stored separately from topical medications and separate from injectable medications.
 
Look-alike/sound-alike medications shall be separated and identified by Tall Man lettering and warning labels.
 
All medication rooms shall have thermometers to monitor room and refrigerator temperatures.
  • Temperatures of the medication room and refrigerators shall be entered into a log on business days with each entry signed by the person responsible for monitoring.
     
    • Medications required to be stored at room temperature shall be stored at a temperature between 59°F (15°C) and 86°F (30°C).
    • Medications requiring refrigeration shall be stored in a refrigerator between 36°F (2°C) and 46°F (8°C).
  • Staff responsible for monitoring temperatures shall notify the DMH Chief of Pharmacy and DMH Chief of Nursing upon discovering medications stored at temperatures outside of range.
     
  • Chief of Pharmacy shall determine disposition of medications and provide instructions to licensed clinic staff.
For all multi-dose vials, personnel who open the vial shall initial and clearly label with expiration date 30 days from the date opened or manufacturer expiration dates, whichever is earlier.
 
Medications shall not be kept in stock after the expiration date on the label; they shall be disposed in accordance with DMH Policy 306.15.
 
Medication expiration dates shall be checked and logged monthly. Expired medications shall be transported to the DMH Pharmacy Service for reverse distribution in accordance with DMH Policy 352.16 Pharmacy Reverse Distribution.
 
Medications stored under conditions outside of manufacturer requirements shall be brought to the immediate attention of DMH Pharmacy Services.
 
IV.  PROCEDURES
 
No procedures are associated with this policy.
 
V.  AUTHORITY
 
California Code of Regulations Title 22 Division 5 Section 70263
 
VI.  ATTACHMENTS
 
ISMP HighAlert AcuteCare List 010924 MS5760
ISMP Look-Alike Tallman Letters