Virginia Administrative Code › Title 18 - PROFESSIONAL AND OCCUPATIONAL LICENSING › Agency 110 - BOARD OF PHARMACY › Chapter 20 - REGULATIONS GOVERNING THE PRACTICE OF PHARMACY › Part VIII - Unit Dose Dispensing Systems › Section 18VAC110-20-420 - Unit dose dispensing system

Current through Register Vol. 40, No. 24, July 15, 2024
A. A unit dose drug dispensing system may be
				  utilized for the dispensing of drugs to patients in a hospital or long-term
				  care facility. The following requirements shall apply regardless of whether
				  licensed or unlicensed persons administer medications:
1. Any equipment outside the pharmacy used to
				  house drugs to be administered in a unit dose system shall be fitted with a
				  locking mechanism and locked at all times when unattended.
2. A signed order by the prescribing
				  practitioner shall accompany the requests for a Schedule II drug, except that a
				  verbal order for a hospital patient for a Schedule II controlled substance may
				  be transmitted to a licensed nurse or pharmacist at the hospital who shall
				  promptly reduce the order to writing in the patient's chart. Such an order
				  shall be signed by the prescriber within 72 hours.
3. Properly trained personnel may transcribe
				  the prescriber's drug orders to a patient profile card, fill the medication
				  carts, and perform other such duties related to a unit dose distribution system
				  provided these are done under the personal supervision of a
				  pharmacist.
4. All dosages and
				  drugs shall be labeled with the drug name, strength, lot number and expiration
				  date when indicated.
5. The
				  patient's individual drug drawer or tray shall be labeled in a manner to
				  identify the patient and his location without violating health privacy
				  laws.
6. All unit dose drugs
				  intended for internal use shall be maintained in the patient's individual
				  drawer or tray unless special storage conditions are necessary.
7. A back-up dose of a drug of not more than
				  one dose unit may be maintained in the patient's drawer, tray, or special
				  storage area provided that the dose is maintained in the patient's drawer,
				  tray, or special storage area with the other drugs for that patient.
8. A record shall be made and maintained
				  within the pharmacy for a period of one year showing:
a. The date of filling of the drug
				  cart;
b. The location of the drug
				  cart;
c. The initials of the person
				  who filled the drug cart; and
d.
				  The initials of the pharmacist checking and certifying the contents of the drug
				  cart in accordance with the provisions in
				  18VAC110-20-270
				  C.
9. A patient profile
				  record or medication card will be accepted as the dispensing record of the
				  pharmacy for unit dose dispensing systems only, subject to the following
				  conditions:
a. The record of dispensing must
				  be entered on the patient profile record or medication card at the time the
				  drug drawer or tray is filled.
b.
				  In the case of Schedule II through V drugs, after the patient profile record or
				  medication card has been completed, the card must be maintained for two
				  years.
c. In the case of the
				  computer-based distribution system, a uniformly maintained "fill list" or other
				  document containing substantially the same information may be accepted as the
				  dispensing record for Schedule II through VI drugs. Records of
				  disposition/administration for floor stock drugs as provided in 18VAC110-20-460
				  B will be accepted for drugs distributed as floor stock.