Standards for the storage of medication

1 Aim

The aim of this document is to set down the standards for the storage of medication.

2 Link to overarching policy

This document links to the overarching safe and secure handling of medicines manual and the inpatient standard operating procedures (opens in new window)

3 Storage of medicines on wards and community teams

The appointed practitioner and team manager in charge is responsible at all times for the safekeeping of all medicines on their ward or department
The design and location of all ward or department medicine storage cupboards must be approved by authorised pharmacy staff and regularly monitored, this should be at a minimum on a quarterly basis by pharmacy staff.
Controlled drugs (CD) schedule 2 and 3 must be stored in a separate designated CD cupboard and recorded in the CD register, the cupboard must be approved by the chief pharmacist.
All internal and external medicines, disinfectants and re-agents must be stored in locked cupboards, trolleys attached to a wall or other secure cabinets, all reserved solely for medicinal products. The only exceptions to this requirement are medicines for clinical emergencies, intravenous fluids, flammable fluids, medical gasses, sterile topical fluids, nutritional products, and some bulky medicated dressings which, because of their bulk, are stored in a clean area (as agreed between the appointed practitioner in charge and an authorized member of the pharmacy staff).
Oxygen storage should be in line with trust guidance (is there a link)
The medicines trolley or computer on wheels (COW) that contain medication may only be removed from its fixings during medicine rounds.
The nurse in charge of the medicines round should be clearly identifiable must never leave the drugs trolley unattended at any time. The nurse and administration technician must not be disturbed during the medicine rounds unless there is a dire emergency. In such an emergency the trolley must be locked.
Internal medicines must be stored separately from other medicines. Under no circumstances must medicines be transferred from one container to another, nor must they be taken out of their container and left loose.
Patients own medication must be stored separately from stock medications for example, individual K-Bins where these are in use.
Patients who self-medicate must have access to an approved secure locker and draw to store their medication.
All medicines in transit must be in a sealed tamper evident container
Where cold storage of medicines is necessary a lockable, temperature controlled and monitored medicines fridge must be made available, which must be reserved solely for the purpose, other items such as food or samples must not be kept in these.

Where the ward or department holds a supply of medicines for use in a medical emergency this will be held in a tamper evident container. This container need not be kept in a locked cupboard but will be located in an area that is most likely to have a constant staff presence that is not obvious to the public, generally in the treatment room.

On some ward areas (and subject to risk assessment) to enable timely treatment the following medicines can be exempted from locked storage:

GTN tablets and spray for the treatment of angina pain (subject to a risk assessment, detailed below)
inhalers of β adreno-receptor agonist as bronchodilators (subject to a risk assessment, detailed below)
Nicotine replacement therapy supplied under a PGD (subject to a risk assessment, detailed below)
Glucagon for the management of hypoglycaemia
Naloxone for the management of opioid overdose
Adrenaline for the management of anaphylaxis

Subject to a risk assessment an individual authorised to administer medicines may assess a patient on an inpatient area as suitable to have control of and take this medicine themselves provided the following conditions are met:

the patient understands what their medicines are for and the how to take them correctly
suitable safe keeping arrangements are available to prevent misuse by others
the medicines are labelled with the patient’s name and instructions for use
a record of the dose and frequency of administration is made on the inpatient drug administration chart

4 Expiry dates

All stock must be checked regularly, and the expiry date highlighted when that date is approaching.
Eye drops must be marked with the date opened and expiry date and disposed of once its expiry has been reached (check individual product for details).
Insulin must be marked when either a vial or pen has been started, and disposed of, if not already used up, after 28 days.
Liquids, the date of opening must be marked on the bottle, and it should be disposed of within 3 months or as marked on the container.

5 Agile working (community)

When agile working any medication stored on trust premises must be in a trust approved area for example, clinic room in line with the above standards. If on the occasional instance where medication is taken home it must be stored securely in line with the storage requirements of that medication, in no circumstances must medications requiring fridge storage (2 to 8^oC) be stored in a staff members home.

When transporting medication in their car it must be in a secure container, kept out of sight, see transporting medication section. Medicines requiring cold storage must be stored in a trust approved cool box (see transport section).

6 Temperature monitoring, overview

The trust have implemented a centralised temperature monitoring system in place of staff taking manual temperature readings; the new system takes a temperature reading every 7.5 minutes.

6.1 Alarm notifications

Should a fridge or room exceed the set temperature parameters the system will send an alarm notification directly to the team. How a team receives an alarm notification has been discussed and arranged with each team individually therefore please speak to your manager to find out the arrangements for your team.

Generally, if a team has a monitored group email address with its own inbox the team will receive an email notification first. If the notification is not responded to after 30 minutes the team will receive a text to speech phone call to the team’s phone number. If the team does not have a group email address, they will only receive a text to speech.

6.2 Resolving a notification

Upon receiving the alarm notification staff are to go to the fridge or room to try to resolve the issue, such as close the fridge door or turn on the air conditioning. Some troubleshooting solutions can be found below

6.3 Fridge

Has the fridge been accidently unplugged or turned off?
Power cut or generator test.

Fridge door left opened:

fridge door been opened for long periods of time due to stock take or delivery
fridge over full air not being allowed to circulate
fridge not having been reset after last recording was taken
build-up of ice or water check the back of the fridge behind shelving may need defrosting
seal around door damaged

6.4 Room

Turn off any lights that are available to be switched off.
Open any available windows.
Check if air con has been switched off if fitted.
Close any blinds.
Check if any radiators that are in close proximity are on and if so switch off or down (speak to estates if unsure).
If there is a fridge in the room consider moving it to a different location, if possible.

Once the issue has been resolved the staff member must log onto
real time (opens in new window) using their team’s username and password to resolve the alarm. A step by step guide can be found below.

Log onto the online system (opens in new window).
Click on ‘monitoring’ located on the menu on the left-hand side.
The click on ‘notifications’.
Here you will see any alarms which have been unacknowledged, those which are acknowledged have been resolved. Find the unacknowledged alarm which related to your fridge or room then click edit.
In the first drop-down box select the most appropriate action taken to resolve the temperature excursion.
Enter a comment to advise what has taken place to resolve the alarm then enter your name and your phone number.
Press save.

If the staff member cannot resolve the issue they must contact pharmacy services for further advice; however, if the fridge is broken then the fridge must be reported to estates via Backtraq (staff access only) (opens in new window).

Alarm notifications must be responded to on the same day, if the notification occurs outside of working hours, then the notification must be responded to on the next working day.

Staff are to log onto the online system (opens in new window) once a week to check their fridge and, or room temperatures are ok and running within temperature. Each team has access to their own team username and pass

7 Medicines storage room ambient temperature monitoring

Unless stated otherwise in product literature and on labels the majority of medicinal products, that do not require refrigeration, can be stored under conditions of controlled room temperature without compromise to their stability and recommended shelf life. These products are usually labelled ‘do not store above 25C
The room temperature is monitored via the centralised temperature monitoring system.
- if the temperature reaches above 26C for more than 7 days, contact pharmacy services for medicines advice with regards to opened liquids. At this temperature and for a short duration tablets, powders and capsules should be stable
- request a visit from the pharmacy team to review the options available to mitigate against this problem if this is likely to be a long term problem
- in the event of a break in monitoring for a prolonged period, the maximum and minimum must be checked via the centralised temperature monitoring system and pharmacy contacted if this is out of range
Complete an incident form with regards to the temperature of the area, and the medicines affected.
The pharmacy team can advise on any changes of expiry due to excessive temperature

8 Drugs fridges

Medicines that require refrigeration should be stored in an approved medicines fridge, which must be used solely for the storage of medicines requiring refrigeration.
The fridge must be connected to the electricity supply in such a manner that does not allow accidental disconnection, for example, attached by a spur to the mains electricity supply or with a cover over the switch.
Medicines must never be stored in the kitchen fridge.
The medicines fridge temperature should be within 2C to 8C.
Pharmacy team or estates must be contacted if there is a problem (area specific).

9 Siting of cupboards or trolleys

Cupboards and trolleys must be sited where most convenient for staff, whilst also allowing adequate space and permitting surveillance to afford maximum security against unauthorised entry. Medicine cupboards will generally not be sited where they may be subjected to higher than average humidity or temperature. Re-agent cabinets, were used, must be sited in area where testing is carried out.

10 CD cupboards

No ward or department must store CD unless there is an appointed practitioner in charge responsible for their storage and use. CD cupboards must be reserved solely for the storage of CD and be secured to the wall.

These cupboards may be separate from others or inside other locked medicines cupboards used to store internal medicines. Keys should be kept with the other drugs keys, although some wards may keep them in a locked key safe.

See standard operating procedures (SOP) for location specific guidance.

11 Community services (patients own medication)

In the community services, the storage of patient’s own medication in their own home, (including CDs) remains the services user’s responsibility, except new beginnings where storage is maintained on patient’s behalf. However, where appropriate, professionals should advise on good storage practice, and be mindful of the patient’s circumstances when delivering medication.

Patient’s medication no longer needed in the community. In the first instance they should be encouraged to take it to their local pharmacy for disposal, if it is brought back to base it should be recorded, and disposed of in approved pharmaceutical waste containers

12 Custody and safe keeping of medicine

12.1 Keys for medicine cupboards, medicine trolleys and drug fridges

Keys for the external medicine cupboard, internal medicine cupboard, medicine trolley, medicine refrigerator must be kept together on one key ring reserved solely for these keys. The keys must be clearly identified.
The keys must be kept on the person of a ward or team manager, in the event of no designated practitioner being on duty in a ward or unit; the keys must be handed to a designated practitioner on a ward or unit in the near vicinity. This information must be made known to the staff on both wards. Where medicines administration is by pharmacy technicians, then they may hold the keys to allow them access.
In a community setting the keys may be held by non-nursing staff, as long as they are authorised by the team leader.
The key must never leave the ward or unit or be left unattended. The designated practitioner should carry them at all times. The only exception being when the designated person is covering for more than one area.
No other person should have access to the medicine cupboards except in the presence of the key holders, with the exception of authorised pharmacy staff for the purpose of stock control.
At community team bases where a number of designated practitioners may require access to the medicine cupboards at different times a secure system must be agreed between the assigned practitioner in charge and the locality pharmacist.
Keys must not be handed over to medical staff or other non-key holders
Lost keys must be reported immediately to the ward and department manager. In the event that the keys cannot be found, all locks must be changed immediately.
Spare keys may be kept, with agreement in a neighbouring ward, normally in the CD cupboard, clearly labelled and accessible only by qualified staff.

12.2 Keys to the CD cupboard

The CD cupboard key must be kept on the person of the assigned practitioner in charge or designated practitioner nominated by them.
Responsibility remains with the assigned practitioner in charge.
No practitioner can have access to the CD cupboard except with the agreement of the practitioner in charge, officially holding the key. The key must not be handed over to medical staff.
Authorised pharmacy staff may have access to the CD cupboard key for the purpose of performing statutory checks.
In the event of the person in charge being inappropriately qualified, the key must be handed to an assigned practitioner in charge of a ward or department in the near vicinity. The information must be made known to staff in both the ward and department and to the manager in charge of that section.

12.3 Re-agent cupboard keys

The key to the re-agent cupboard will be kept separately and, in a place, designated by the appointed practitioner in charge.

13 Containers for storage of medicines

Pharmacy does not re-use plastic or glass bottles. When empty, plastic bottles may be disposed of in the normal rubbish bags. Oral, non-toxic liquids may be returned to pharmacy. Empty glass bottles may be disposed of in the usual way. Child resistant containers (CRCs) are used routinely on discharge items. If a member of the ward staff feels that CRC’s would be difficult for the patient to open they should contact the supplying pharmacy to discuss suitable alternatives.

Document control

Version: 2.
Unique reference number: 553.
Date ratified: 7 March 2023.
Ratified by: Clinical policy review and approval group.
Name of originator: Medicines management committee.
Name of responsible individual: Executive medical director.
Date issued: 26 March 2023.
Review date: 31 March 2026.
Target audience: Trust wide.
Description of changes: Review, minor updates and clarification.

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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