21 N.C. Admin. Code 46 .1413 - ABSENCE OF PHARMACIST

(a) When a health care facility pharmacy is not open 24 hours a day, seven days a week, arrangements shall be made in advance by the pharmacist-manager for provision of drugs and pharmaceutical care to the medical staff, other authorized personnel, and patients of the health care facility by use of an "on call" pharmacist accessible to the facility during all absences, and auxiliary medical inventories as described in Rule .1414(d) of this Section. In addition, one or both of the options in Subparagraphs (a)(1) and (2) may be authorized by the pharmacist-manager to assure access to drugs and pharmaceutical care in the absence of a pharmacist:
(1) a contractual arrangement with another health care facility, pharmacy, or pharmacist; or
(2) a nurse trained and authorized by the pharmacist-manager to remove drugs or devices from the pharmacy in the absence of a pharmacist. Entry into the pharmacy in the absence of a pharmacist shall occur only if the drug needed is not in the auxiliary medication inventory. The pharmacist-manager shall maintain a current list of authorized persons and document the initial orientation, continuing education, and quality control processes on an ongoing basis. The pharmacist-manager shall maintain a list of restricted medications that shall not be taken from the pharmacy and may only be removed after contacting the "on call" pharmacist to verify the appropriateness and accuracy of the medication order and medication removed from the pharmacy at the time of removal. For medications not on the restricted list, an "on call" pharmacist must be accessible for questions by the authorized nurse. Within 24 hours, a pharmacist shall verify the accuracy and appropriateness of the medication order and the medication removed from the pharmacy.
(b) A record of drugs or devices removed from auxiliary medication inventories or from pharmacy inventory shall be maintained for three years in the health care facility in compliance with all applicable laws and regulations. The pharmacist-manager shall at least quarterly verify the accuracy of the records.
(c) Supportive personnel approved by the pharmacist-manager may be present in the pharmacy at other than regular service hours to perform clerical, repackaging and distributive functions according to written policies and procedures if the drugs so handled are not permitted to leave the pharmacy until all work performed has been checked and certified as being correct by the pharmacist.
(d) Only drugs in unit-of-use packaging shall be removed from the auxiliary medication inventory or from the pharmacy; they shall be used for administration to a specific patient only, in amounts sufficient to meet the needs for immediate therapeutic requirements. Controlled substances may be stocked and removed from auxiliary medication inventories; controlled substances may not be removed from the pharmacy in the absence of a pharmacist. Drugs shall be pre-labeled by the pharmacist with drug name, strength, lot number and expiration date. A copy of written orders for new medications shall be provided to the pharmacy.


21 N.C. Admin. Code 46 .1413
Authority G.S. 90-85.6; 90-85.21; 90-85.32; 90-85.33; 90-85.34;
Eff. May 1, 1997;
Amended Eff. March 1, 2013; August 1, 2000.

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