Compilation of Rules and Regulations of the State of Georgia
Department 480 - RULES OF GEORGIA STATE BOARD OF PHARMACY
Chapter 480-13 - HOSPITAL PHARMACY REGULATIONS
Rule 480-13-.04 - Absence of Pharmacist
Current through Rules and Regulations filed through March 20, 2024
(1) General. When a licensed pharmacist is not physically present in the hospital and the pharmacy is closed, written policies and procedures shall be prepared in advance by the Director of Pharmacy for the provision of drugs to the medical staff and other authorized personnel of the hospital by use of night cabinets and/or by access to the pharmacy. The policies and procedures may include the use of remote order entry pharmacist to ensure that in-patient needs are met at the hospital when a licensed pharmacist is not physically present. All policies and procedures providing for the use of night cabinets and/or access to the pharmacy when a licensed pharmacist is not physically present shall be made available to the Georgia State Board of Pharmacy, its designee, or a representative of the Georgia Drugs and Narcotics Agency (GDNA), upon request.
(2) A hospital utilizing a remote order entry pharmacist shall maintain a record of the name and address of such pharmacist, evidence of current licensure in the State of Georgia, and the address of each location where the pharmacist will maintain records of remote order entries.
(3) A hospital pharmacy shall be authorized to utilize remote order entry when:
(4) Before a hospital may engage in remote order entry as provided in this paragraph, the director of pharmacy of the hospital shall submit to the board written policies and procedures for the use of remote order entry. The required policies and procedures to be submitted to the board shall be in accordance with the American Society of Health-System Pharmacists and shall contain provisions addressing:
(5) Each remote entry record must comply with all recordkeeping requirements and shall identify, by name or other unique identifier, the pharmacist involved in the preview and verification of the order. The remote entry pharmacist shall maintain records of any and all records entered for the hospital for a minimum of two (2) years, and such records shall be readily available for inspection, copying by, or production of upon request by the Board, its designee, or a representative for the Georgia Drugs and Narcotics Agency (GDNA), upon request.
(6) If the board concludes that the hospital's actual use of remote order entry does not comply with this rule or O.C.G.A. 26-4-80, it may issue a cease and desist order after notice and hearing.
(7) Night cabinets. Access to drugs, in the absence of a licensed pharmacist, shall be by locked cabinet(s) or other enclosure(s) constructed and located outside of the pharmacy area to which only specifically authorized personnel as indicated by written policies and procedures may obtain access by key or combination, and which is sufficiently secure to deny access to unauthorized persons. The Director of Pharmacy shall, in conjunction with the appropriate committee of the hospital, develop inventory listings of those drugs to be included in such cabinet(s) and shall insure that:
(8) Access to pharmacy. Whenever a drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy pursuant to the practitioner's order and the requirements of this subsection. One nursing supervisor (registered professional nurse or licensed practical nurse) in any given shift may have access to the pharmacy and may remove drugs there from. Such licensed nurse shall be designated in writing by the Director of Pharmacy of the hospital and shall, prior to being permitted to obtain access to the pharmacy, receive thorough education and training approved by the Director of Pharmacy, in the proper methods of access, removal of drugs, and records and procedures required. The Director of Pharmacy, or designee, shall document the nurse's competence following the education and training. In addition, such licensed nurse accessing a closed pharmacy must receive specific step-by-step instructions in a policy manual, approved by the Director of Pharmacy, before accessing the pharmacy. At any time that a nurse is accessing a closed pharmacy, the Director of Pharmacy must designate a licensed pharmacist, not a remote order entry pharmacist, who is available to the nurse by telephone, and who, in the event of an emergency, is available to come to the hospital. When a nurse accesses drugs directly from the closed pharmacy, the nurse must:
(9) Emergency kits/crash carts. Drugs may also be provided for use by authorized personnel by emergency kits/crash carts, provided such kits/carts meet the following requirements:
(10) Authoritative, current antidote information as well as the telephone number of the regional poison control information center shall be readily available in areas outside the pharmacy where these drugs are stored.
(11) Nothing in this rule shall be construed to relieve the hospital pharmacy of the requirement of having an on-site pharmacist to provide routine pharmacy services within the hospital in order to qualify as a licensed pharmacy.
O.C.G.A. §§ 26-4-5, 26-4-27, 26-4-28, 26-4-80, 26-4-83, 26-4-84, 26-4-110.