Pharmacy Safety & Security

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Maintaining strong safety and security practices is essential for pharmacies to prevent unauthorized access and diversion of controlled substances. Federal and state regulations require pharmacies to implement physical safeguards, control access, monitor activity, and ensure accountability across all staff. 

This guide outlines the key components of an effective pharmacy security program, including access control, staff responsibilities, facility protections, and monitoring systems. 

Controlled Access to Pharmacy Areas 

Access to secured pharmacy and dispensing areas must be strictly limited to authorized personnel. 

• Physical Barriers 
  Pharmacies should maintain secure infrastructure such as:  
  • Locked doors and gates  
  • Controlled entry points  
  • Limited-access service windows  
  • Additional state-required safeguards  
• Visitors & Non-Employees 
  When non-employees (e.g., inspectors, repair personnel) require access:  
  • Identity must be verified (e.g., work order, credentials)  
  • Visitors must sign a log  
  • Visitors must be escorted at all times  
  • Steps should be taken to restrict access to controlled substances  
  • Follow all state-required safeguards 

Employee Eligibility & Screening 

Not all individuals are permitted to handle controlled substances. 

• Individuals with certain disqualifying histories (e.g., felony convictions related to controlled substances or DEA registration denial/revocation) must not have access unless a formal exception is granted by the DEA.  
• Pharmacies should conduct pre-employment screening and periodic checks to ensure ongoing eligibility.  

Staff Access Controls 

Access to the pharmacy and controlled substances should be limited based on role and credentials. 

• Only authorized staff may enter secured areas or handle controlled substances  
• Access levels should be defined and periodically reviewed for accuracy  
• Changes in roles or employment status should trigger immediate access updates  

Staff Identification 

All pharmacy personnel should be clearly identifiable while on duty. 

• Name Badges should include:  
  • Company name and logo  
  • Employee first name  
  • Job title/role  
  • Any state-required information and formatting (e.g. font, size, etc.) 
• Badges must be worn at all times and returned upon termination  
• Temporary badges should meet the same standards  

Key & Lockbox Security 

Lockboxes 

• Must be securely mounted in discreet locations  
• Access limited to authorized personnel  
• Codes should be changed when staff leave  

Pharmacy Keys 

• Issued only to authorized staff (typically pharmacists)  
• Duplication should be strictly controlled  
• All keys must be returned upon termination  
• Locks should be changed if keys are not returned or are lost  

Controlled Substance Safes & Cabinets 

If controlled substances are stored in safes or cabinets: 

• Units must remain locked when not in use  
• Key Access:  
  • Keys must remain with authorized staff  
  • Never stored in visible or unsecured locations  
• Code Access:  
  • Limited to authorized personnel  
  • Shared securely  
  • Changed promptly when staff leave  

Alarm Systems 

Pharmacies should utilize alarm systems to detect unauthorized access. 

• Common Features:  
  • Door and gate sensors  
  • Motion detectors  
  • Glass break sensors  
  • Panic buttons  
  • Access tracking and alerts  
• Best Practices:  
  • Arm system when pharmacy is closed or unattended  
  • Restrict system access to authorized staff  
  • Change codes when staff leave  
  • Perform regular testing and maintenance  
• Incident Response 
  Alarm triggers should notify designated staff and, when appropriate, local law enforcement.  

Video Surveillance 

Continuous video monitoring enhances security and supports investigations. 

• 24/7 surveillance with recorded footage  
• Footage should be retrievable when needed  
• Systems should be regularly tested and maintained  

Employee Termination Procedures 

When an employee leaves the pharmacy, all access must be promptly revoked. 

This includes: 

• Name badge  
• Keys and lockbox codes  
• Alarm system access  
• Power of attorney (POA)/Controlled substance ordering systems (e.g., CSOS)  
• Pharmacy software and vendor access  
• Email and internal systems  

Timely deactivation reduces risk of unauthorized access. 

Personal Belongings & Workspace Controls 

To reduce diversion risk: 

• Personal items (bags, coats, purses) should be stored away from dispensing areas  
• If no breakroom is available, designate a secure, separate storage area  
• Food and drinks are not allowed in controlled substance areas  
• Only clear containers may be permitted in certain areas, depending on policy  

Landlord & Third-Party Access (Leased Spaces) 

In leased pharmacy locations: 

• Landlords or third parties should not access the pharmacy without proper authorization and supervision  
• Access should occur only with prior notice and in the presence of authorized pharmacy personnel  
• Lease agreements should clearly define these restrictions whenever possible  

A strong pharmacy safety and security program combines physical safeguards, controlled access, staff accountability, and continuous monitoring. By maintaining these practices, pharmacies can reduce diversion risk, protect sensitive inventory, and remain compliant with regulatory expectations. 

Disclaimer: These tools and templates are intended for general informational purposes and are provided by Montana Family Pharmacies as a service to pharmacies. While we try to keep the information timely and accurate, we make no guarantees. These tools and templates are not a substitute for legal, regulatory, or professional advice. 

Policies and procedure, templates, checklists, and other tools should be customized to fit the specific needs and regulatory requirements of your pharmacy. 

Montana Family Pharmacies disclaims any liability for any damages, losses, or other consequences arising from the use or reliance on the tools or policy templates.