Effective Date of This Revision: January 9, 2009
Contact: Medical Director 310-679-9126, Administration
Applies to:
• Officers
• Other agents
• Staff
• Visitors
• Student clinicians
• Contractors
• Volunteers
• Subcontractors / Business Associates
PURPOSE:
The purpose of this document is to outline policy and procedures for the destruction of discontinued and defective medications in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.
POLICY:
Discontinued, defective, outdated, and otherwise unusable facility-acquired medications shall be destroyed in a consistent and organized manner that conforms to state and federal regulations and provides a record of destroyed medications.
PROCEDURES:
Outdated, defective and otherwise unusable facility-acquired stock medications shall be destroyed as follows:
• The pharmacist shall send Schedule II, III, or IV controlled drugs to the local Drug Enforcement Administration for destruction, using the proper DEA form.
• Other legend drugs not listed above shall be documented for destruction by a pharmacist or licensed nurse using the Medication Disposal Log.
• Products must be destroyed by an outside agency that has appropriate facilities. They may be placed in sharps container or a red bag labeled hazardous waste and picked up by the hazardous waste disposal company.
Medications obtained for patients from facility stock shall not be sent home with the patient, even if the medication is prescribed for the patient at the time of discharge.
Over-the-counter medications not obtained from the contract pharmacy for the patient shall not be sent home with the patient.
Remaining medications that have been ordered from the contract pharmacy for an individual patient and later discontinued, and medications brought in by the patient that remain in the facility more than seven (7) days after the patient is discharged shall be destroyed as follows:
• Schedule II, III, and IV controlled drugs shall be destroyed in the presence of a pharmacist and a licensed nurse, at least one of whom is retained or employed by the facility. A notation of such destruction shall be made in the Medication Disposal Log, including the name of the patient, name and strength of the drug, the prescription number, and name of dispensing pharmacy, the amount destroyed, the date of destruction, and the signatures of both witnesses.
• A pharmacist or a licensed nurse and one witness shall destroy drugs not listed above. A notation of such destruction shall be made in the Medication Disposal Log, including the name of the patient, name and strength of the drug, the prescription number and name of dispensing pharmacy, the amount destroyed, the date of destruction, and the signatures of the individual(s) involved.
• Medication Destruction Log shall be retained for at least three (3) years.
Prescription medications which have been ordered from the contract pharmacy for the individual patient and which the patient continues to have prescribed at the time of discharge may be sent home with the patient if so ordered by the physician upon discharge. Over-the-counter medications that have been obtained from the contract pharmacy, for the individual patient, may be sent home with the patient at discharge, if authorized by the physician.
No medications obtained from facility stock shall be sent home with the patient.
Drug products identified as possibly defective shall be reported to the ASHP-USP-FDA Drug Product Problem Reporting Program, and removed from circulation.
