Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 21 - Drug Distribution › Section 310:667-21-2 - Personnel

Current through Vol. 41, No. 20, July 1, 2024
(a)
Pharmacist director or
				consultant.
The pharmacist director or consultant shall be responsible
				for all drugs that come into the hospital. The pharmacist shall be trained in
				the specialized functions of hospital pharmacy and be responsible to the
				administrator for developing, supervising, and coordinating all activities of
				the pharmacy or drug room, whether on a full-time or consultant basis. The
				consultant pharmacist shall visit the hospital a minimum of fifty-two (52)
				times per year, with no more than five (5) visits in any one month counted
				toward this total, and shall submit a report outlining issues encountered and
				decisions made during the visit. The responsibility and authority of the
				pharmacist shall be clearly defined in a written job description. The
				responsibilities include but are not limited to:
(1) Establishes and implements
				intradepartmental and interdepartmental written policies and procedures
				regarding methods of reconciliation and control of drugs, including audit
				trails governing all areas of pharmaceutical services. These policies and
				procedures shall be in compliance with local, state, and federal laws and
				current professional principles and practices.
(2) Establishes liaison with the
				administrator and the chief of the medical staff regarding written policies and
				procedures and their interaction and interdependency with the requirements of
				the medical staff bylaws and rules and regulations, the governing body rules
				and regulations, and administrative interdepartmental policies.
(3) Employs an adequate number of pharmacists
				and other personnel, as required by department activities and services to
				implement pharmaceutical services.
(4) Provides drug information services to
				physicians and licensed independent practitioners, dentists, nurses, and other
				health care staff.
(5) Provides
				poison information services to physicians and licensed independent
				practitioners, dentists, nurses, and other health care staff.
(6) Provides inservice training to physicians
				and licensed independent practitioners, nurses, pharmacy staff, and other
				personnel as applicable.
(7)
				Provides documentation that orientation and staff-development training are
				provided to pharmacy personnel. Documentation shall include but not be limited
				to:
(A) Formal orientation of new personnel
				to written policies of the department.
(B) Inservice education and staff
				development.
(C) Specialized
				training in admixture service.
(D)
				Outline of program content.
(E)
				Signatures of staff attending with title.
(8) Provides records of tax-free alcohol,
				investigational drugs, and controlled dangerous drug substances, as required by
				local, state, and federal laws, rules and regulations.
(9) Provides reviews of patient drug orders
				and requisitions to avoid possible errors in medication
				administration.
(10) Maintains a
				stock of drugs, as agreed in the formulary or drug list, for daily and
				emergency use.
(11) Develops
				quality assurance methods to determine that the activities of the department
				are within the interdepartmental and intradepartmental policies and
				procedures.
(12) Reports all
				deficiencies identified through quality assurance methods and the methods of
				correction of deficiencies to the chief executive officer, the departmental
				chief, and/or the pharmacy and therapeutics committee.
(13) Provides reports of all visits by the
				consulting pharmacist. The reports include documentation of consultation with
				the administrator or the administrator's designee. A copy of the consultant's
				visit reports shall be retained in the drug room.
(14) Make copies of current policies and
				procedures available to all appropriate personnel.
(15) Provides an agreement with other
				licensed pharmacists for provision of outside pharmacy services in case of
				emergency.