Kansas Administrative Regulations
Agency 28 - DEPARTMENT OF HEALTH AND ENVIRONMENT
Article 34 - HOSPITALS
Section 28-34-10a - Pharmacy services

(a) General provisions. Each hospital shall provide pharmaceutical services which are administered in accordance with accepted ethical and professional practices.

(b) Organization and staffing. The pharmaceutical service shall be directed by a licensed pharmacist. If the hospital has a pharmacy, it shall be directed by a licensed pharmacist. If the hospital does not have a pharmacy or a full-time staff pharmacist, a pharmacist employed on a part-time or consultant basis shall be responsible for control and dispensing of drugs and for operation of the pharmacy or the pharmaceutical functions of nursing stations. In addition to meeting the standards in this regulation, services shall be provided in accordance with K.A.R. 68-7-11 and amendments thereto.

(c) Pharmacy facilities. Each hospital that maintains a pharmacy on its premises shall provide adequate equipment, supplies and facilities for the storage, safeguarding, preparation and dispensing of drugs. Drugs and biologicals must be kept in locked storage areas. Drugs requiring refrigeration shall be stored in conveniently located refrigerators which shall be used for drug storage only.

(d) Pharmacy and therapeutics committee. Each hospital shall establish a pharmacy and therapeutics committee or its equivalent. The committee shall consist of at least physicians, nurses and pharmacists. This committee shall assist in the formulation of broad professional policies regarding evaluation, appraisal, selection, procurement, storage, distribution and use of drugs and safety procedures and all other matters relating to drugs in the hospital. This committee shall meet at least quarterly, record its proceedings and report to the medical staff.

(e) Policies and procedures. The pharmaceutical service shall develop written policies and procedures. These policies shall be reviewed by the medical staff at least annually and shall be dated to indicate the date of last review. Procedures shall be established for the recording of all drug dispensations or other pharmacy transactions of the pharmacy or nursing stations.

(f) Medications dispensed. The hospital pharmacy shall dispense from a formulary of drugs approved by the medical staff through its appropriate committees. Any drug approved by the food and drug administration for use as an experimental drug may be used in accordance with standards established by the hospital's medical staff.

(g) Commercial pharmaceutical service. Each hospital using an outside pharmacist or pharmaceutical service shall have a contract with that pharmacist or service. As part of the contract, the pharmacist or service shall be required to maintain at least the standards for operation outlined in these regulations.