Oklahoma Administrative Code › Title 535 - Oklahoma State Board of Pharmacy › Chapter 15 - Pharmacies › Subchapter 6 - Hospital Drug Room › Section 535:15-6-5 - Drug room and PIC responsibilities and duties

Current through Vol. 41, No. 20, July 1, 2024
(a)
Responsibilities.
Responsibilities of the hospital drug room and PIC include drug purchasing,
				acquisition, preparation, distribution, monitoring, security, storage and
				control.
(1)
Written procedures.
The hospital drug room and PIC shall establish written procedures for the safe
				and efficient acquisition, distribution, and utilization of all medicine
				products with any of the Federal legends such as "RX only" and medications
				administered or distributed in the hospital system. A current copy of such
				procedures shall be available for review by the Board.
(2)
General Responsibility.
The
				hospital drug room and PIC shall be responsible for the safe and efficient
				monitoring, distribution, control, purchasing, acquisition and accountability
				of all drugs including but not limited to Federal legend drug products used in
				diagnostic procedures, I.V. fluids, or contained in supply kits excluding blood
				bank products and reagents controlled by the laboratory. The other professional
				staff of the hospital facility shall cooperate with the pharmacist in meeting
				this responsibility.
(3)
Confidentiality.
The hospital drug room and PIC shall have
				responsibility for establishing policies for the security and integrity of any
				patient information, confidential and non-confidential, and must abide by all
				relevant State and Federal regulations applicable to the hospital
				system.
(4)
Adverse Drug
				Events Program.
The hospital drug room and PIC shall develop and
				maintain a program to monitor the actual and potential adverse drug events
				including pharmacist interventions, medication errors, and adverse drug
				reactions for all medications utilized in the hospital to include system wide
				programs if an integrated system is involved. Records indicating the tracking,
				review, and outcome of the Adverse Drug Events shall be kept current and
				available for Board inspection.
(5)
Investigational drug programs.
The PIC shall establish a policy
				for investigational drug use.
(6)
Review of medication orders.
The PIC shall cause medication orders
				to be reviewed by a 100 pharmacist in a timely manner.
(7)
Pharmacists Visits.
The
				hospital drug room and PIC shall cause and document a minimum of 52 routine
				in-house visits per year to be made to a hospital with a drug room as required
				by health department rule OAC
				310:667-21-2(a)
				et seq.
(A) No more than 2 visits in any
				7-day period shall be counted towards this minimum.
(B) No more than 5 visits in any one month
				count toward the 52 visit total for the year.
(C) Visits in any calendar month shall be no
				less than 2.
(D) The PIC shall
				submit a report outlining issues encountered and decisions made during visits.
				A copy of this report shall be available in the hospital drug room for
				inspection by the Board.
(E) A
				licensed hospital drug room employing a full-time pharmacist is not required to
				document the 52 routine in-house visits since daily work is done, interventions
				are documented, and audit systems are maintained.
(8)
Pharmacy and Therapeutics (P&T)
				Committee.
The PIC shall be a participating member in the Pharmacy and
				Therapeutics Committee.
(9)
Effective Controls.
The hospital drug room and PIC shall establish
				and maintain effective controls against the diversion of prescription drugs
				into other than legitimate medical, scientific, or industrial channels as
				provided by federal, state or local laws or rules.