Utah Admin. Code R432-100-26 - Pharmacy Services
(1) The pharmacy of
a licensee currently accredited and conforming to the standards of Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) is determined
to be in compliance with this section. If a licensee is not accredited by
JCAHO, then the licensee's pharmacy services shall comply with rules in this
section.
(2) A licensed pharmacist
shall direct the pharmacy department and service.
(3) The licensee shall employ personnel in
keeping with the size and activity of the department and service.
(4) If the licensee uses only a drug room and
the size of the hospital does not warrant a full-time pharmacist, a consultant
pharmacist may be employed.
(5) The
pharmacist is responsible for developing, supervising, and coordinating the
activities of the pharmacy.
(6) The
licensee shall provide access to emergency pharmaceutical services.
(7) The licensee shall ensure the pharmacist
is trained in the specific functions and scope of the hospital
pharmacy.
(8) The licensee shall
provide facilities for the safe storage, preparation, safeguarding, and
dispensing of drugs and ensure the following:
(a) floor-stocks are kept in secure areas in
the patient care units;
(b)
double-locked storage is provided for controlled substances and electronically
controlled storage of narcotics is permitted if automated dispensing technology
is utilized by the hospital;
(c)
medications stored at room temperatures are maintained between 59 and 80
degrees Fahrenheit (F);
(d)
refrigerated medications are maintained between 36 and 46 degrees F.;
and
(e) a current toxicology
reference, and other references as needed for effective pharmacy operation and
professional information are available.
(9) The licensee shall maintain records of
the transactions of the pharmacy and medication storage unit and coordinated
with other hospital records.
(10)
(a) The licensee shall maintain a recorded
and signed floor-stock controlled substance count once per shift or the
facility that shall use automated dispensing technology in accordance with
Section R156-17b-605.
(b) A licensee that utilizes automated
dispensing technology shall implement a system for accounting of controlled
substances dispensed by the automated dispensing system.
(c) The record shall list the name of the
patient receiving the controlled substance, the date, type of substance,
dosage, and signature of the person administering the substance.
(11)
(a) The director of the pharmaceutical
department or service shall develop written policies and procedures, in
coordination with the medical staff, that pertain to the intra-hospital drug
distribution system and the safe administration of drugs.
(b) Medical staff shall administer drugs that
are provided to floor units in accordance with hospital policies and
procedures.
(c) The medical staff,
in coordination with the pharmacist, shall establish standard stop orders for
medications not specifically prescribed in regard to time or number of
doses.
(d) The pharmacist shall
have full responsibility for dispensing of drugs.
(e) The licensee shall ensure there is a
policy stating who may have access to the pharmacy or drug room when the
pharmacist is not available.
(f)
The licensee shall ensure there is a documentation system for the accounting
and replacement of drugs, including narcotics, to the emergency
department.
(g) The licensee shall
ensure medication errors and adverse drug reactions are reported immediately in
accordance with written procedures including notification of the practitioner
who ordered the drug.
Notes
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