Current through Register Vol. 30, No. 38, September 20, 2024
A. Each hospital pharmacy shall be directed
by a pharmacist who is licensed to engage in the practice of pharmacy in
Arizona and is referred to as the Director of Pharmacy. The Director of
Pharmacy shall be the pharmacist-in-charge, as defined in A.R.S. §
32-1901
or shall appoint a pharmacist-in-charge. The Director of Pharmacy and the
pharmacist-in-charge, if a different individual, shall:
1. Be responsible for all the activities of
the hospital pharmacy and for meeting the requirements of the Arizona Pharmacy
Act and these rules;
2. Ensure that
the policies and procedures required by these rules are prepared, implemented,
and complied with;
3. Review
biennially and, if necessary, revise the policies and procedures required under
these rules;
4. Document the review
required under subsection (A)(3);
5. Assemble the policies and procedures as a
written manual or by another method approved by the Board or its designee;
and
6. Make the policies and
procedures available within the pharmacy for employee reference and inspection
by the Board or its designee.
B. In all hospitals, a pharmacist shall be in
the hospital during the time the pharmacy is open for pharmacy services, except
for an extreme emergency as defined in
R4-23-110. Pharmacy
services shall be provided for a minimum of 40 hours per week, unless an
exception for less than the minimum hours is made upon written request by the
hospital and with express permission of the Board or its designee.
C. In a hospital where the pharmacy is not
open 24 hours per day for pharmacy services, a pharmacist shall be "on-call" as
defined in
R4-23-651 when the
pharmacy is closed.
D. The Director
of Pharmacy may be assisted by other personnel approved by the Director of
Pharmacy in order to operate the pharmacy competently, safely, and adequately
to meet the needs of the hospital's patients.
E. Pharmacists. A pharmacist or a pharmacy
intern or graduate intern under the supervision of a pharmacist shall perform
the following professional practices:
1.
Verify a patient's medication order before administration of a drug to the
patient, except:
a. In an emergency medical
situation; or
b. In a hospital
where the pharmacy is open less than 24 hours a day for pharmacy services, a
pharmacist shall verify a patient's medication order within four hours of the
time the pharmacy opens for pharmacy services;
2. Verify a medication order's pharmaceutical
and therapeutic feasibility based upon:
a. The
patient's medical condition,
b. The
patient's allergies,
c. The
pharmaceutical and therapeutic incompatibilities, and
d. The recommended dosage limits;
3. Measure, count, pour, or
otherwise prepare and package a drug needed for dispensing, except a pharmacy
technician or pharmacy technician trainee may measure, count, pour, or
otherwise prepare and package a drug needed for dispensing under the
supervision of a pharmacist according to written policies and procedures
approved by the Board or its designee;
4. Compound, admix, combine, or otherwise
prepare and package a drug needed for dispensing, except a pharmacy technician
may compound, admix, combine, or otherwise prepare and package a drug needed
for dispensing under the supervision of a pharmacist according to written
policies and procedures approved by the Board or its designee;
5. Verify the accuracy, correct procedure,
compounding, admixing, combining, measuring, counting, pouring, preparing,
packaging, and safety of a drug prepared and packaged by a pharmacy technician
or pharmacy technician trainee according to subsections (E)(3) and (4) and
according to the policies and procedures in subsection (G);
6. Supervise drug repackaging and check the
completed repackaged product as specified in
R4-23-402(A);
7. Supervise training and education in
aseptic technique and drug incompatibilities for all personnel involved in the
admixture of parenteral products within the hospital pharmacy;
8. Consult with the medical practitioner
regarding the patient's drug therapy or medical condition;
9. When requested by a medical practitioner,
patient, patient's agent, or when the pharmacist deems it necessary, provide
consultation with a patient regarding the medication order, patient's profile,
or overall drug therapy;
10.
Monitor a patient's drug therapy for safety and effectiveness;
11. Provide drug information to patients and
health care professionals;
12.
Manage the activities of pharmacy technicians, pharmacy technician trainees,
other personnel, and systems to ensure that all activities are performed
accurately, safely, and without risk of harm to patients;
13. Verify the accuracy of all aspects of the
original, completed medication order; and
14. Ensure compliance by pharmacy personnel
with a quality assurance program developed by the hospital.
F. Pharmacy technicians and
pharmacy technician trainees. Before working as a pharmacy technician or
pharmacy technician trainee, an individual shall meet the eligibility and
licensure requirements prescribed in 4 A.A.C. 23, Article 11.
G. Pharmacy technician policies and
procedures. Before employing a pharmacy technician or pharmacy technician
trainee, a Director of Pharmacy or pharmacist-in-charge shall develop the
policies and procedures required under
R4-23-1104.
H. Pharmacy technician training program.
1. A Director of Pharmacy or
pharmacist-in-charge shall comply with the training program requirements of
R4-23-1105 based on the needs of the hospital pharmacy;
2. A pharmacy technician or pharmacy
technician trainee shall:
a. Perform only
those tasks for which training and competency have been demonstrated;
and
b. Not perform professional
practices reserved for a pharmacist, graduate intern, or pharmacy intern in
subsection (E), except as specified in subsections (E)(3) and (4).
I. Supervision. A
hospital pharmacy's Director of Pharmacy and the pharmacist-in-charge, if a
different individual, shall supervise all of the activities and operations of a
hospital pharmacy. A pharmacist shall supervise all functions and activities of
pharmacy technicians, pharmacy technician trainees, and other hospital pharmacy
personnel to ensure that all functions and activities are performed
competently, safely, and without risk of harm to patients.
