Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part I - General Administration › Subpart 3 - Licensing and Certification › Chapter 93 - Hospitals › Subchapter D - Pharmaceutical Services › Section I-9353 - Delivery of Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
					 compounding, packaging, and dispensing of drugs, biologicals, legend and
					 controlled substances shall be accomplished in accordance with Louisiana law
					 and Board of Pharmacy regulations and be performed by or under the direct
					 supervision of a registered pharmacist currently licensed to practice in
					 Louisiana.
B. Dispensing of
					 prescription legend or controlled substance drugs direct to the public or
					 patient by vending machines is prohibited.
C. Current and accurate records shall be
					 maintained on the receipt, distribution and dispensing of all scheduled drugs
					 in such a manner as to facilitate complete accounting for the handling of these
					 controlled substances. An annual inventory, at the same time each year, shall
					 be conducted for all schedule I, II, III, IV and V drugs.
D. A hospital outpatient pharmacy shall
					 maintain all records and inventory separate and apart from that of the
					 inpatient pharmacy, and shall require a separate pharmacy permit to
					 operate.
E. Medications are to be
					 dispensed only upon written orders, electromechanical facsimile, or oral orders
					 from a physician or other legally authorized prescriber, and be taken by a
					 qualified professional.
F. All
					 inpatient drug containers shall be labeled to show at least the patient's full
					 name, room number, the chemical or generic drug's name, strength, quantity and
					 date dispensed unless a unit dose system is utilized. Appropriate accessory and
					 cautionary statements as well as the expiration date shall be included. Floor
					 stock containers shall contain the name and strength of the drug, lot and
					 control number or equivalent, and the expiration date. In unit dose systems,
					 each single unit dose package shall contain the name and strength of the drug,
					 lot and control number or equivalent, and expiration date. Outpatient drug
					 containers shall be labeled to show at least the patient's full name, the
					 prescriber's name, the chemical or generic drug's name, directions, name of the
					 pharmacy and pharmacist, prescription number, and appropriate accessory and
					 cautionary statements. Outdated, mislabeled or otherwise unusable drugs and
					 biologicals shall be separated from useable stock, shall not be available for
					 patient or other use and shall be returned to an authorized agency for credit
					 or destroyed according to current state or federal laws as
					 applicable.
G. Drugs and
					 biologicals not specifically prescribed as to time or number of doses shall
					 automatically be stopped after a reasonable time that is predetermined by the
					 medical staff.
H. The director of
					 pharmacy shall develop and implement a procedure that in the event of a drug
					 recall, all employees involved with the procurement, storage, prescribing,
					 dispensing and administering of recalled drugs in the facility will be notified
					 to return these drugs to the pharmacy for proper disposition.
I. Drug administration errors, adverse drug
					 reactions, and incompatibilities shall be immediately reported to the attending
					 physician, pharmacist and, if appropriate, to the hospital-wide quality
					 assessment and improvement program. An entry shall be made in the patient's
					 record.
J. Abuses and losses of
					 controlled substances shall be reported to the individual responsible for
					 pharmaceutical services, the chief executive officer, the Louisiana Board of
					 Pharmacy, and to the Regional Drug Enforcement Administration (DEA) office, as
					 appropriate.
K. Information
					 relating to drug interactions, drug therapy, side effects, toxicology, dosage,
					 indications for use and routes of administration shall be available to the
					 staff.
L. A formulary system shall
					 be established by the appropriate hospital committee to assure quality
					 pharmaceuticals at reasonable costs, subject only to the restrictions of
					 R.S.
					 37:1226.1 and LAC 46:LIII.1109.B.6.
M. Naloxone nasal spray, as an
					 over-the-counter (OTC) non-prescription drug, may be distributed by the
					 hospital to patients and/or non-patients who present in the hospital. Other non
					 OTC formulations and dosages of naloxone will remain available by prescription
					 only.
AUTHORITY
						NOTE: Promulgated in accordance with R.S.
						40:2100-2115.