West Virginia Code of State Rules › Agency 64 - Health › Title 64 - LEGISLATIVE RULE WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 64-12 - Hospital Licensure › Section 64-12-7 - Paramedical Storage

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1.
				Pharmaceutical Service.
7.1.1. A licensed
				pharmacist shall be responsible for developing, supervising, and coordinating
				all pharmacy services, including the distribution of samples, provided at the
				hospital.
7.1.2. The pharmacist may
				be employed on a full-time, part-time, or consulting basis.
7.1.3. All compounding, packaging, and
				dispensing of drugs and biologicals shall be under the supervision of a
				pharmacist and performed consistent with federal and state laws.
7.1.4. All drugs, including drugs stored
				outside the pharmacy, shall be stored in locked cabinets, medication rooms, or
				medication carts approved by the Director of Pharmacy. This shall ensure the
				integrity of the medications and safety for the patients and the general
				population. It shall further ensure medications are only accessible to
				authorized personnel according to hospital policy.
7.1.5. When a pharmacist is not available,
				drugs and biologicals may be removed from the pharmacy or storage area only by
				personnel authorized in accordance with federal and state law and hospital and
				medical staff policies.
7.1.6.
				Drugs and biologicals not specifically prescribed as to a time or number of
				doses shall be stopped after a reasonable period of time which is
				pre-determined by medical staff policy.
7.1.7. All medication storage areas shall
				have a designated area or compartment for the separate storage of external
				medications.
7.1.8. The medication
				preparation area shall be clean, well illuminated and have adequate space for
				the storing and preparation of medications.
7.1.9. Narcotics and controlled drugs which
				are required to conform to federal or state regulations or rules shall be kept
				within a secure storage area accessible only to authorized personnel.
7.1.10. Surplus narcotics or narcotics with
				an expired date shall be disposed of according to applicable federal and state
				regulations.
7.1.11. A record shall
				be maintained, or a system developed, to track the receipt and distribution of
				controlled drugs.
7.1.12. Outdated,
				mislabeled, or otherwise unusable drugs and biologicals shall not be accessible
				for patient use.
7.1.13. Except for
				medication packaged for unit doses, all unused medications shall be discarded
				when orders have been discontinued or the patient has been discharged from the
				hospital.
7.1.14. Drug
				administration errors, adverse drug reactions, and incompatibilities shall be
				immediately reported to the attending practitioner and Director of Pharmacy and
				investigated using current and readily accessible drug and patient information.
				This information shall be evaluated as part of the hospital quality improvement
				program.
7.1.15. The medical staff
				shall establish a formulary system and review it as necessary.
7.1.16. The Director of Pharmacy shall
				provide a system for the recognition and treatment of any drug/drug product or
				food/drug interactions and incompatibilities.
7.1.17. Drugs and biologicals shall be
				prepared and administered in accordance with:
7.1.17.a. Federal and state law;
7.1.17.b. The orders of the practitioner or
				practitioners responsible for the patient's care; and
7.1.17.c. Accepted standards of
				practice.