Health Care Department Operations Manual

Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

3.5.22 Emergency Drug Supplies

Procedure Overview
- Emergency medications necessary for life support shall be available in emergency medication storage units (treatment carts, drawers, or cabinets). Only emergency medications as approved by the California Correctional Health Care Services Systemwide Pharmacy and Therapeutics (P&T) Committee shall be stocked in treatment carts. Treatment carts shall be secured in Triage and Treatment Areas (TTAs) or, if permitted by the institution Emergency Medical Response Review Committee (EMRRC), designated licensed units. Pharmacists shall inspect the emergency medication storage units during monthly medication area inspection rounds.
Purpose
- To ensure the availability of approved life support medications required for emergency care. This procedure applies to emergency medication storage and maintenance only and does not apply to medical equipment or supplies.
Procedure
- Maintenance of Emergency Life Support Medication Supply
  - The Pharmacist-in-Charge (PIC) and the Chief Nurse Executive (CNE), or their designees, shall ensure that approved emergency medications are available, secure, and accessible at all times in treatment carts.
  - Only approved emergency medications for life support (Appendix 1) shall be stocked in treatment carts in designated locations as determined by the institution EMRRC, except as specified in Section (c)(2)(D).
    - The institution EMRRC may, in coordination with the PIC, establish treatment cart medication quantities greater than the statewide requirements to meet local institution needs.
    - If the institution EMRRC, in coordination with the PIC, determines that other medications (e.g., intranasal naloxone, epipens) are necessary for emergency response specific to their patient population, these medications shall be stored outside the treatment carts in secured locations to ensure appropriate health care access only. The institution EMRRC in coordination with the PIC shall establish the appropriate quantity of emergency medications based upon approved statewide emergency protocols.
  - Treatment carts shall be secured and sealed with a red tamper-resistant, numbered seal which must be broken to gain access to the medications.
  - Medications stored in treatment carts used for Advanced Cardiac Life Support shall be independently secured and accessed only by licensed nursing staff or by a Licensed Independent Practitioner. Refer to Lifeline on the Pharmacy Resources page for Emergency Medical Response Program (EMRP): Treatment Cart Lockable Tray to Secure Advanced Cardiac Life Support Medications at: Treatment Cart Lockable Tray to Secure Advanced Cardiac Life Support Medications.
  - A CDCR 7529, Treatment Cart Medication Inventory Log, of the medication contents of each treatment cart shall be attached to the outside of the cart in a readily visible place. The log shall include the number from the red seal, date affixed, and the initials of the pharmacist affixing the seal. The inventory log shall include the following information for each medication contained in the cart:
    - Generic name
    - Dosage form
    - Strength
    - Quantity (as determined by institution EMRRC and statewide minimums)
    - Shortest expiration date
  - The CNE, or designee, is responsible for ensuring the integrity of the red seal. Nursing staff shall record the treatment cart red seal number(s) and verify refrigerated medication after daily inspection on the CDCR 7544, Treatment Cart Daily Check Sheet.
- Managing Treatment Cart Medications During Drug Shortages
  - The PIC, or designee, shall document a drug shortage by placing an order for the drug and receiving a zero ship quantity confirmation from the prime vendor. The PIC, or designee, shall attempt to purchase the drug through a state-contracted pharmaceutical vendor by contacting headquarters Pharmacy Services at: m_CCHCSRxSupplyChain@cdcr.ca.gov.
  - The PIC, or designee, shall order unavailable approved treatment cart medications on a monthly basis as stated in Section (c)(2)(A).
  - The PIC, or designee, shall maintain the existing medication on the cart up to the business day prior to its expiration date but continue all efforts to obtain replacement during this time. The PIC shall ensure removal of the expiring medication.
  - Alternatives to the approved treatment cart inventory shall be permitted when procurement is not possible due to drug shortages. Alternatives shall be permitted for variations in salt, strength and packaging. When using a salt variation, the PIC, or designee pharmacist, shall confirm that the medication is approved by the Food and Drug Administration for the intended indication prior to placement in the treatment cart. For off-label use, approval by the Systemwide P&T Committee shall be obtained prior to placement in the treatment cart.
  - Alternative medications in the treatment cart shall be marked with “high alert” auxiliary labels, precautions, and dose/administration directions.
  - The CDCR 7529, Treatment Cart Medication Inventory Log, affixed to the outside of the treatment cart shall be updated to reflect the alternative medication.
  - Alternative medications shall be replaced when approved treatment cart medications are received.
- Re-sealing the Treatment Cart After Opening
  - A yellow seal indicates the treatment cart was opened and is awaiting replenishment and verification of medications by a pharmacist. A red, numbered seal indicates the treatment cart medications have been verified by a pharmacist and that the treatment cart is ready for use. Only pharmacy staff shall have access to red, numbered seals.
  - Whenever the red seal has been broken, a licensed health care staff member shall secure the treatment cart with a yellow seal stocked in the treatment cart. The CNE, or designee, shall notify pharmacy immediately after the red seal has been broken or by the start of the next pharmacy business day. Nursing staff and a pharmacist shall coordinate replacement of medications and supplies before sealing with a red, numbered seal by the end of the pharmacy business day.
  - When medications are used, the CNE, or designee, shall provide pharmacy with the associated patient name and CDCR number.
  - A pharmacist shall thoroughly inventory the contents of the opened or unsealed treatment cart, replace any medication used, and document any medication replenished on the CDCR 7545, Pharmacy Treatment Cart Replenishment Log.
  - The institution EMRRC and the PIC shall develop a process to address the possibility of insufficient treatment cart stock after pharmacy business hours.
  - The pharmacist shall re-seal the treatment cart with a red seal and replace the CDCR 7529, Treatment Cart Medication Inventory Log.
- Pharmacy Inspections
  - Once a month during medication storage area inspections, a pharmacist shall evaluate and inspect emergency treatment carts for integrity of the red seal and expiring medications. Except in the case of drug shortages as in Section (c)(2)(C), medications expiring within the next 30 calendar days shall be replaced at the time of inspection.
  - Problems noted during the monthly inspection of treatment carts shall be documented consistent with the Health Care Department Operations Manual, Section 3.5.25, Inspecting Medication Storage Areas.
Appendices
- Appendix 1: Approved Treatment Cart Medications with Minimum Required Quantities
References
- California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72377, Pharmaceutical Service – Equipment and Supplies
- California Code of Regulations, Title 22, Division 5, Chapter 4, Article 3, Section 73375, Pharmaceutical Service – Equipment and Supplies
- California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79671, Pharmaceutical Service – Equipment and Supplies
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.25, Inspecting Medication Storage Areas
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.26, Break-In, Theft/Loss From Pharmacy or Medication Storage Areas
Revision History
Effective: 11/2009
Revised: 05/06/2024
Reviewed: 02/11/2026

Appendix 1: Approved Treatment Cart Medications with Minimum Required Quantities

**Treatment Cart Medication List	Minimum Quantity
Adenosine, 3mg/mL, 2mL Vial	3
Amiodarone HCl INJ, 50mg/mL, 3mL Vial	3
Aspirin, 325mg non-coated Tablets	5
Atropine, 0.1mg/mL, 10 mL Syringe	4
Calcium Chloride, 10%, 10mL Syringe	2
Dextrose, 10%, 250mL Pre-mixed Bag (preferred) OR Dextrose, 50%, 50mL Syringe	2
Digoxin, 0.25mg/mL, 2mL Ampule	3
Diphenhydramine, 50mg/mL, 1mL Vial	3
*Diltiazem, 5mg/mL, 5mL Vial	3
Epinephrine 1:1,000, 1mg/mL, 1mL Ampule	3
Epinephrine 1:10,000, 0.1mg/mL, 10mL Syringe	6
Furosemide, 10mg/mL, 10mL Vial	2
Glucagon HCl, 1mg kit INJ	2
Lidocaine 2%, 20mg/mL, 5mL Syringe	2
*Lorazepam 2mg/mL, 1 mL	5
Magnesium Sulfate 50%, 0.5g/mL, 2mL Vial	4
Methylprednisolone Sod. Succ., 125mg/2mL Vial	2
Metoprolol, 1mg/mL, 5mL Vial	3
Naloxone, 0.4mg/mL	12
Naloxone, 2mg/2mL	5
Nitroglycerin SL, 0.4mg #25 Tab Bottle	2
Nitroglycerin, 2% Top Ointment, 1g Unit Dose	8
Sodium Bicarbonate, 50mEq/50mL, 8.4% Syringe	3
Sodium Chloride, 0.9%, 10mL Vial	5

*Diltiazem and lorazepam (controlled substance) are refrigerated items. They shall not be stored in the treatment cart but shall be immediately available in a secured, refrigerated location near the treatment cart.
**If one or more of the above listed medications is unavailable due to shortages, refer to Section (c)(2), Managing Treatment Cart Medications During Drug Shortages.