May 7, 2026·8 min read

Setting Up a Medication Pass Station: Complete Supply Checklist

Every consumable, tool, and reference document you need to stand up a medication pass station or med cart. With case-pack quantities and PAR levels by facility size.

By Wayne Campo

Setting Up a Medication Pass Station: Complete Supply Checklist

Standing up a new medication pass station — whether you're opening a new wing, converting a space, or re-standardizing an older one — is one of those projects where forgetting a $15 item can hold up a $5,000 week. This is the checklist we use when facility managers ask us what they actually need to order.

It's organized by category, with PAR levels sized for a typical 100-bed facility. Scale the numbers proportionally.

Disposable cups & containers

0.75 oz paper souffle cups (CUP-75OZ-SOUF) — 1 case (5,000) per ~3–4 weeks at typical 100-bed pass volume
0.75 oz translucent plastic souffle cups (CUP-75OZ-PLAS) — alternate when staff need to verify contents at a glance; same 5,000/case pack
3 oz wax-coated cups (CUP-3OZ-WAX) — 1 case (5,000) quarterly for liquid-medication or larger-portion needs
5 oz translucent cold cups (CUP-5OZ-COLD) — 1 case (2,500) per two weeks for hydration alongside the pass
Souffle cup lids — optional; order only if your cart workflow pre-sets trays

To size your own PAR rather than copying these numbers, multiply (residents × med-passes/day × cups/pass × buffer factor) and divide by case pack to get cases/period. The PAR table at the bottom of this post does that math for the four common facility sizes.

Oral dose support tools

Pill crushers (single-use disposable or reusable with cleaning protocol) — 1 per cart, spare in supply room
Pill splitters — 1 per cart, spare in supply room
Oral syringes (1 mL, 5 mL, 10 mL) — one box each, for specific liquid-med workflows
Straws (flexible, individually wrapped) — 1 box of 500 per month

Hand hygiene & PPE

Alcohol-based hand sanitizer (ABHR) — one wall-mount dispenser per cart plus one pump bottle on the cart itself
Nitrile gloves (S, M, L, XL) — one box of each size per cart. PAR refill on depletion
Surface disinfectant wipes (EPA List N for bloodborne pathogens; EPA List K for C. diff if applicable) — one canister on cart + spare in supply room
Face masks — per current facility policy

Documentation & reference

Medication Administration Record (MAR) — paper backup even if your facility is 100% electronic
Facility med-pass policy (printed, in a sheet protector, on the cart)
Poison Control phone number (1-800-222-1222) — printed and visible
Emergency-response flowchart — printed and visible
Current formulary (printed or tablet-accessible)

Cart hardware

Locking medication cart — confirm key management protocol
Wheel locks that actually engage (surprisingly often an issue)
Tray inserts sized for your cup SKUs
Narcotic lockbox inside the cart if schedule-II medications are administered from it
Sharps container — 1 mounted on cart
Trash receptacle on cart (lined with color-coded biohazard bag if required)

Refrigeration

Small medication-only refrigerator at the station (not a shared break-room fridge — JC/CMS-pointable violation)
Fridge thermometer with daily log sheet
Insulated transport bag if meds travel between rooms

Stocking workflow

The PAR sheet for the cart should be visibly attached to the cart itself, not just filed centrally. Nursing or med-tech reviews it at the end of each shift; supply manager replenishes twice weekly.

A common mistake: letting the cart's cup supply drop below half a day's worth before replenishing. The cart should hold two days of cups at the low water mark; three days is a better policy. Ordering cups is cheap; running out in the middle of a pass is expensive.

PAR quantities by facility size

Facility bed count	0.75 oz souffle / week	3 oz wax cups / month	5 oz cold cups / week
50 beds	1,200	1,500	500
100 beds	2,500	3,000	1,000
200 beds	5,000	6,000	2,000
300 beds	7,500	9,000	3,000

These are rough upper-bound estimates assuming roughly 2.5 medication-pass events per resident per day and one water cup per pass. Pull your actual consumption from last quarter's invoices to calibrate for your facility's mix.

Documentation for a new setup

When you stand up a new station, you want a single sheet on the cart documenting:

Date of setup, who set it up
Who approved the PAR levels
Replenishment schedule
Key holder / custody protocol
First scheduled audit date (within 30 days is good practice)

Joint Commission and state surveyors often ask for this. Having it on the cart rather than filed in a cabinet saves the conversation.

FAQ

How many cups does a 100-bed facility actually use per week? With ~2.5 medication passes per resident per day and one souffle cup per pass, expect roughly 1,750 souffle cups per week — round up to a half-case buffer for missed-PAR weeks. The PAR table above uses 2,500/week as a safe upper bound that absorbs occasional spikes from new admissions or workflow changes.

Should the cart hold its own PAR or pull from central supply? Both. The cart should hold two days of cups, gloves, and prep pads at the low water mark; central supply replenishes twice weekly. Carts that pull every dose live with constant stockout risk — and stockouts happen during the pass, when there's no time to fix them.

Do I need a separate medication-only refrigerator? Yes. Joint Commission and CMS surveyors flag shared break-room fridges holding patient medications as a finding; it's one of the most common citations on smaller-facility surveys. A counter-top medication fridge is under $300 and avoids the documentation overhead of contesting a finding.

What's the right reorder cadence for cart consumables? Twice-weekly is the sweet spot. Daily is too much administrative overhead; weekly leaves too much stockout risk on the high-velocity SKUs (cups, gloves). Most facilities settle into a Tuesday/Friday cycle that aligns with delivery windows from their primary distributor.