Louisiana Administrative Code
Title 46 - PROFESSIONAL AND OCCUPATIONAL STANDARDS
Part LIII - Pharmacists
Chapter 15 - Hospital Pharmacy
Section LIII-1509 - Drug Distribution Control
Universal Citation: LA Admin Code LIII-1509
Current through Register Vol. 50, No. 9, September 20, 2024
A. The hospital pharmacist-in-charge shall be responsible for the safe and efficient procurement, receipt, distribution, control, accountability, and patient administration and management of drugs. The staff of the hospital pharmacy shall cooperate with the pharmacist-in-charge in meeting drug control requirements in ordering, administering, and accounting for pharmaceuticals.
1. Procedure Manual. The pharmacist-in-charge
shall maintain written procedures for the safe and efficient distribution of
pharmaceutical products and delivery of pharmacy care. An updated copy shall be
available for board inspection upon request.
2. Inventories. The pharmacist-in-charge
shall:
a. perform an annual inventory on all
controlled dangerous substances; and
b. maintain a perpetual inventory of Schedule
I and II controlled dangerous substances.
3. Records. The pharmacist-in-charge shall be
responsible for maintaining the following records:
a. a record of all drugs procured, the
quantity received, and the name, address and wholesale distributor license
number of the person from whom the drugs were procured;
b. all drug orders and records relating to
the practice of pharmacy:
i. records of drugs
dispensed shall include, but are not limited to:
(a). the name, strength, and quantity of
drugs dispensed;
(b). the date of
dispensing;
(c). the name of the
hospital patient to whom, or for whose use, the drug was dispensed;
and
(d). positive identification of
all pharmacists involved in the dispensing;
ii. all other records relating to the
practice of pharmacy other than dispensing shall include, but are not limited
to:
(a). the name of the hospital patient to
whom, or for whose benefit, the activity was performed;
(b). the nature of the pharmacy practice
activity performed;
(c). the
results of the activity, if applicable; and
(d). positive identification of all
pharmacists involved in the activity; identifying the function performed by
each pharmacist;
iii.
Records of drugs dispensed to patients for use outside the hospital shall be
maintained in compliance with
Section
1123 of this Part.
c. a record of all drugs
compounded or prepackaged for use only within that hospital, which shall
include at least the following:
i. name of
drug, strength, quantity, and dosage form;
ii. manufacturer's or distributor's control
number (except for patient-specific sterile compounded preparations);
iii. manufacturer's or distributor's name, if
a generic drug is used;
iv.
pharmacy control number;
v.
manufacturer's or distributor's expiration date (except for patient-specific
sterile compounded preparations);
vi. pharmacy's expiration date or beyond-use
date;
vii. identification of the
licensed person responsible for the compounding or prepackaging of the
drug;
d. a record of the
distribution of drugs to patient care areas and other areas of the hospital
held for administration, which shall include at least the following:
i. the name, strength, dosage form, and
amount of the drug distributed;
ii.
the area receiving the drug;
iii.
the date distributed;
iv.
identification of the individual receiving the drug if it is a controlled
dangerous substance;
v. the area of
the hospital receiving the controlled dangerous substance shall make a record
of all such drugs administered to patients. Such records shall include at least
the following:
(a). name of the
patient;
(b). name, dosage form,
and strength when applicable of the drug;
(c). date and time the drug was
administered;
(d). quantity
administered;
(e). positive
identification of the personnel administering the drug;
e. a log that shall be maintained
of all changes made to a drug record in an electronic drug recordkeeping system
after a drug transaction has been made. The log shall contain at least, but is
not limited, to the following:
i. date and
time of change;
ii. changes
made;
iii. person making the
change.
B.Automated Medication Systems. A hospital pharmacy may use one or more automated medication systems in compliance with the provisions of Chapter 12 of this Part.
1.
When the pharmacy uses an electronic product verification process as described
in Section 1217 of
this Part, and in the absence of any subsequent human intervention in the
automated drug product selection process, the pharmacist-in-charge may elect to
forego manual checks of drug products selected in that manner, provided
however, that such selection by the pharmacist-in-charge shall require an
initial quality assurance validation followed by an ongoing quality review at
intervals no greater than 90 days since the previous review, all conducted by a
pharmacist.
2. The
pharmacist-in-charge remains accountable to the board for the accuracy of all
drug distribution activities.
AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1182.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
