Oregon Administrative Rules › Chapter 855 - BOARD OF PHARMACY › Division 41 - OPERATION OF PHARMACIES › Section 855-041-6840 - Drug Distribution and Control from a Drug Room in a Hospital

Current through Register Vol. 63, No. 7, July 1, 2024
(1) General. The
			 director of pharmacy shall establish and implement written procedures for the
			 safe and efficient distribution of pharmaceutical products. An annually updated
			 copy of such procedures shall be available for inspection by the
			 Board.
(2) Availability. A
			 pharmacist providing pharmaceutical services to a hospital maintaining a drug
			 room shall be engaged by the hospital and shall schedule on-premises visits on
			 at least a weekly basis.
(3) Span
			 of Control. The pharmacist's span of supervision shall extend to all areas of
			 the hospital where drugs are stored. No less than every two months inspections
			 of these areas shall be conducted and substantiated by records so as to verify
			 at least proper drug storage, documentation of distribution and administration
			 of controlled substances, absence of outdated drugs, and the integrity of the
			 required emergency drug supply.
(4)
			 Director's Absence. In the absence of the director of the pharmaceutical
			 service, pharmaceutical services shall be directed by a designated
			 pharmacist.
(5) Responsibility. The
			 director of pharmacy shall be responsible for procedures for the safe and
			 efficient distribution of, control of and accountability for drugs.
			 Accordingly, the director shall be responsible for, at a minimum, the
			 following:
(a) Procedures for preparation and
			 sterilization of parenteral medications manufactured within the
			 hospital;
(b) Procedures for
			 admixture of parenteral products, including education and training of nursing
			 personnel concerning incompatibility and provision of proper incompatibility
			 information. When the admixture of parenteral products is not accomplished
			 under the direct supervision of a pharmacist, such preparation shall be limited
			 to a practitioner or registered nurse;
(c) Manufacture and compounding of
			 drugs;
(d) Procedures for
			 establishment of specifications for procurement of all pharmaceutical
			 materials, including drugs, chemicals and biologicals, subject to approval of
			 the appropriate committee of the hospital;
(e) Procedures for participation in the
			 development and revisions of a hospital formulary system;
(f) Procedures for filling and labeling all
			 stock containers from which drugs are to be administered;
(g) Maintaining and making available a
			 sufficient inventory of antidotes and other emergency drugs, as well as current
			 antidote information, telephone numbers of poison control center(s) and other
			 emergency assistance organizations, and such other materials and information as
			 may be deemed necessary by the appropriate committee of the hospital;
(h) Records of all transactions of the
			 hospital relating to pharmaceutical services as may be required by state or
			 federal law, and maintenance of accurate control over and accountability for
			 all pharmaceutical materials. The procedures shall include the keeping of
			 accurate and complete records of the receipt, withdrawal from stock and use or
			 other disposal of all legend drugs stored in the drug room and all other
			 locations in the hospital;
(i)
			 Participation in those aspects of the hospital's patient care evaluation
			 program which relate to pharmaceutical material utilization and
			 effectiveness;
(j) Meeting all
			 inspection and other requirements of the pharmacy and drug laws of this state
			 and rules thereunder.