New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 9 - PHARMACEUTICAL SERVICES › Section 8:43A-9.3 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall develop and implement
				written policies and procedures, approved by the patient care policy committee, for
				the administration, control, and storage of medications. The patient care policy
				committee shall review the policies and procedures and document the review at least
				annually.
(b) The facility's policies
				and procedures for the administration, control, and storage of medications shall
				include, but not be limited to, policies and procedures for the following;
1. Documenting and reviewing adverse drug
				reactions and medication errors;
2.
				Discontinuing drug orders, including, but not limited to, the length of time drug
				orders may be in effect, for drugs not specifically limited as to duration of use or
				number of doses when ordered, including intravenous infusion solutions;
3. The control of the administration of toxic and
				dangerous drugs, including at least narcotics, sedatives, anticoagulants,
				antibiotics, oxytoxics, corticosteroid products, intravenous infusion solutions, and
				other drugs specified in the facility's policies and procedures;
4. The use of parenterals, if used, including the
				labeling of intravenous infusion solutions, such that a supplementary label is
				affixed to the container of any intravenous infusion solution to which drugs are
				added;
5. The purchase, storage,
				safeguarding, accountability, use, and disposition of drugs, in accordance with the
				New Jersey State Board of Pharmacy Rules, N.J.A.C. 13:39, and the Controlled
				Dangerous Substances Acts and amendments thereto. Pharmaceutical services provided
				through written agreement shall be provided by a pharmacy licensed by the New Jersey
				State Board of Pharmacy. An individual patient may choose to obtain medications from
				a pharmacy which is not located in New Jersey;
6. The procurement, storage, use, and disposition
				of needles and syringes in accordance with all applicable Federal and State laws and
				rules, including those specified at
				N.J.A.C.
				8:43A-14.6(b). All needles and
				syringes shall be kept in locked storage areas;
7. The control of drugs subject to the Controlled
				Dangerous Substances Acts and amendments thereto, in compliance with the New Jersey
				State Board of Pharmacy Rules, N.J.A.C. 13:39, and all other Federal and State laws
				and regulations concerning procurement, storage, dispensing, administration, and
				disposition. Such policies and procedures shall include, but not be limited to, the
				following:
i. Provision for a verifiable record
				system for controlled drugs;
ii.
				Policies and procedures to be followed in the event that the inventories of
				controlled drugs cannot be verified or drugs are lost, contaminated, unintentionally
				wasted, or destroyed. A report of any such incident shall be written and signed by
				the persons involved and any witnesses present; and
iii. In all areas of the facility where drugs are
				dispensed, administered, or stored, procedures for the intentional wasting of
				controlled drugs, including the disposition of partial doses, and for documentation,
				including the signature of a second person who shall witness the
				disposition;
8. The security
				of the keys or codes to locked drug storage areas, including specification of the
				personnel who may retain the keys or security codes. Only licensed nursing or
				medical personnel shall retain the keys or security codes to storage areas in which
				drugs subject to the Controlled Dangerous Substances Acts and amendments thereto are
				kept;
9. The control and limitation of
				use of drugs marked "sample";
10. The
				maintenance of records of prescribers' Controlled Dangerous Substance registration
				numbers and Drug Enforcement Administration registration numbers for New Jersey; and
11. Up-to-date pharmaceutical reference
				materials to be provided at locations specified in the facility's policies and
				procedures and made available to medical and nursing staff.
i. The telephone number of the designated
				Statewide or regional New Jersey Poison Information and Education System (1-800-
				222-1222 ) shall be provided at locations specified in the facility's policies and
				procedures.
ii. Current Federal and
				State drug law information shall be available to the pharmaceutical
				service.
iii. A list of abbreviations,
				metric apothecary conversion charts, and a list of chemical symbols, approved by the
				medical staff, shall be kept in areas where medications are prepared for
				administration.