Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 21 - Drug Distribution › Section 310:667-21-8 - Drug handling

Current through Vol. 41, No. 20, July 1, 2024
(a) Drugs shall be
				given to hospital patients only upon written order of a physician or
				practitioner legally authorized to write a prescription, with the exception of
				influenza and pneumococcal polysaccharide vaccines, which may be administered
				per physician-approved hospital policy after an assessment for
				contraindications. No change in an order shall be made without the approval of
				the prescriber. Telephone or verbal orders are discouraged but, when necessary,
				shall be written by an authorized employee and signed by the person legally
				authorized to write a prescription or meet the requirements at OAC
				310:667-19-2(c)(4).
				The person taking the telephone or verbal order shall read the order back to
				the physician or practitioner to ensure it was correctly understood and verify
				on the order the fact that the order was read back. Each facility, within its
				own procedures and protocols, shall establish a verification process to be
				placed on orders to demonstrate that the order was read back to the
				physician.
(b) Single use units of
				controlled substances shall be used in the hospital except in the pharmacy
				where multiple dose vials may be used for IV admixtures.
(c) All Schedule drugs in the hospital,
				except those in the pharmacy, shall be verified by actual count at the change
				of shift by two (2) licensed nurses and documented. Schedule drugs outside the
				pharmacy which are contained in, and controlled by, an automated dispensing
				device may be verified by actual count at the time of each access and
				documented. Adequate day-to-day accountability-of-use records shall be
				maintained and shall include the date and time of each check of a schedule drug
				substance supply, the balance on hand, the names of patients receiving drugs,
				the physician's or prescribing practitioner's name, quantity of medication used
				and wasted, and the signatures of the two persons making the check. Wastage of
				schedule drugs shall be witnessed by at least two (2) persons, one (1) of which
				shall be a licensed health professional. Witnesses shall document wastage by
				signature.
(d) The medical staff
				shall establish a written policy that all toxic or dangerous drugs not
				specifically prescribed as to time or number of doses shall be automatically
				stopped after a reasonable time limit set by the staff. Examples of drugs
				ordinarily thought of as toxic or dangerous drugs include: controlled
				substances, sedatives, anticoagulants, antibiotics, oxytocics, and
				steroids.
(e) The administrator, or
				his or her authorized representative, shall inventory pharmacy controlled
				substances and alcohol at least annually.
(f) Drugs past the date of expiration shall
				be removed from stock and shall not be available for patient use.
Added at 12 Ok Reg 1555, eff 4-12-95
				  (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 18 Ok Reg 2032,
				  eff 6-11-01; Amended at 20 Ok Reg 1664, eff 6-12-03; Amended at 24 Ok Reg 1189,
				  eff 4-2-07 (emergency); Amended at 25 Ok Reg 2472, eff 7-11-08; Amended at 30
				  Ok Reg 1966, eff 7-25-13