Or. Admin. Code § 855-041-6310 - After Hours Access to Pharmacy

When a drug required to treat the immediate needs of a patient is not available from floor-stock or a night cabinet, it may be obtained from the pharmacy in accordance with the following procedures:

(1) Only one registered nurse supervisor on a shift may have access to the pharmacy and may remove drugs. The nurse supervisor must be designated in writing by the appropriate hospital committee and prior to being permitted to obtain access to the pharmacy, must receive appropriate training in the proper procedures for access, removal of drugs, and recordkeeping;

(2) The PIC or designee must give such education and training, and must require, at a minimum, the following procedures:

(a) A drug may only be removed from the pharmacy on a practitioner's order that has been posted to the patient's medical record;

(b) A copy of the practitioner's order must be left either with the container from which the drug was removed or with an identical unit-dose, and must be placed conspicuously for a pharmacist to verify for accuracy;

(c) A record of each drug removed from the pharmacy by the nurse supervisor must include:

(A) Name and hospital location of the patient;

(B) Name and strength of drug distributed;

(C) Units used;

(D) Date and time of distribution;

(E) Initials of the nurse supervisor distributing the drug;

(F) Date and initials of the pharmacist who confirmed the accuracy of the transaction.

Notes

Or. Admin. Code § 855-041-6310

BP 3-2010, f. 4-29-10, cert. ef. 4-30-10

Stat. Auth.: ORS 689.205

Stats. Implemented: ORS 689.155 & 689.605