OAR 855-041-6800: Supervision of Consulting Pharmacist

(1) In a hospital having a drug room and no pharmacy, the drug room must be supervised by a licensed pharmacist who provides his or her services with sufficient professionalism, quality and availability to adequately protect the safety of the patients and to properly serve the needs of the facility. The arrangements for a consulting pharmacist shall be in writing, and shall, at a minimum, provide that: (a) The pharmacist is to act in the capacity of a part-time director; (b) The pharmacist shall provide on-call service at all times; (c) Adequate storage facilities for drugs will be provided; and (d) All drugs supplies shall be labeled so as to insure that recalls can be effected and that proper control and supervision of such drugs may be exercised. (2) One registered nurse supervisor and only one in any given shift may have access to the drug room and may remove drugs therefrom, except in an emergency situation. In that case, such nurse may designate another licensed nurse to obtain the required drug(s). Any access to the drug room deviating from the requirements of this section must be approved by the Board prior to implementation. The registered nurse supervisor shall be designated in writing by the appropriate committee of the hospital and shall, prior to being permitted to obtain access to the drug room, receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training shall be given by the director of pharmacy, who shall require, at a minimum, the following records and procedures: (a) Drugs can only be removed from the drug room on a practitioner's written order, or verbal order which has been reduced to writing; (b) A log of drugs withdrawn from a drug room shall be maintained and initialed by the registered nurse; (c) Drugs shall be removed for outpatients only in compliance with section (3) of this rule. (3) The consultant pharmacist who is the part-time director of pharmaceutical services shall in concert with the appropriate committee of the hospital medical staff, develop policies and procedures which shall be implemented to provide emergency pharmaceuticals to outpatients during the hours when normal community or hospital pharmacy services are not available. Such policies shall allow the designated registered nurse supervisor to issue medications pursuant to the pharmacist's standing orders, which shall provide: (a) A written order of a practitioner authorized to prescribe a drug is presented; (b) The medication is prepackaged by a pharmacist and contains: (A) Name, address and telephone number of the hospital; (B) Name of drug, strength, and number of units; when a generic name is used, the label shall also contain the name of the manufacturer or distributor; (C) Required precautionary information regarding controlled substances; (D) Such other and further accessory cautionary information as required for patient safety; (E) An expiration date after which the patient should not use the medication. (c) No more than a 24-hour supply is provided to the patient, except when the pharmacist has informed the nurse supervisor that normal services will not be available within 24 hours; (d) The container is labeled by the nurse supervisor before presenting to the patient, and shows the following: (A) Name of patient; (B) Directions for use to the patient; (C) Date; (D) Identifying number; (E) Name of prescribing practitioner; (F) Initials of the supervisor. (e) The original written order by the prescriber is retained for verification by the pharmacist after completion by the nurse supervisor and shall bear: (A) Name and address of patient; (B) Date of issuance; (C) Units issued; (D) Initials of supervisor issuing medication. (f) The original written order is verified by the pharmacist, initialed, dated, and filed in a separate location for a period of three years for Board inspection; (g) The withdrawal of a single dose for immediate administration to the patient need not follow the requirements of subsection (d) of this section. (4) Emergency Kits: (a) Emergency Kit Drugs Defined. Emergency kit drugs are those drugs which may be required to meet the immediate therapeutic needs of in-patients, and which are not available from any other authorized source in sufficient time to prevent risk of harm to patients by delay resulting from obtaining such drugs from such other source; (b) Supplying Pharmacist. All emergency kit drugs shall be prepared by a licensed pharmacist; (c) Drugs Included. The director of pharmacy and the medical staff of the hospital shall jointly determine and prepare a list of drugs, by identity and quantity, in amounts sufficient for immediate therapeutic requirements, to be included in emergency kits. Such list of drugs shall be reviewed annually by the appropriate medical staff committee; (d) Storage. Emergency kits shall be stored in areas to prevent unauthorized access and to insure a proper environment for preservation of the drugs within them, as required in official compendia; (e) Labeling — Interior. All drugs contained in emergency kits shall be labeled in accordance with OAR 855-041-6420; (f) Labeling — Exterior. The exterior of emergency kits shall be labeled to clearly and unmistakably indicate that it is an emergency drug kit and it is for use in emergencies only; such label shall also contain a listing of the name, strength and quantity of the drugs contained therein and an expiration date; (g) Expiration Date. The expiration date of an emergency kit shall be the earliest expiration date on any drug supplied in the kit. Upon the occurrence of the expiration date, the supplying pharmacist shall open the kit and replace expired drugs; (h) Removal of Drugs. Drugs shall be removed from emergency kits by authorized personnel only pursuant to a valid order or by the supplying pharmacist; (i) Notifications. Whenever an emergency kit is opened or has expired, the supplying pharmacist shall be notified and the pharmacist shall restock and reseal the kit within a reasonable time so as to prevent risk of harm to patients.