Current through Register Vol. 51, No. 19, September 20, 2024
A. The director of pharmacy shall participate
in the development and maintenance of the formulary for emergency drugs and
supplies that are maintained throughout the institutional facility.
B. The director of pharmacy or designee
shall, in conjunction with the medical staff of the institutional facility,
develop and implement written policies and procedures to ensure compliance with
the provisions of this regulation.
C. The institutional pharmacy shall furnish
emergency drugs and supplies only if:
(1) The
emergency drugs and supplies are stored in an environment which:
(a) Maintains the integrity of the drugs;
and
(b) Provides accessibility only
to authorized personnel;
(2) The institution follows a policy that
drugs will be dispensed from the emergency drugs and supplies formulary only
upon written or verbal order by an authorized prescriber;
(3) The emergency drugs and supplies are
stocked and maintained in a manner that complies with the standards of
applicable State law;
(4) The
emergency drugs and supplies are:
(a) Stored
and secured:
(i) With a tamper evident seal;
or
(ii) Via electronic means;
and
(b) Kept in a secure
area;
(5) The emergency
drugs and supplies are labeled as follows:
(a)
Clearly indicating that the emergency drugs and supplies are for use in
emergencies only;
(b) Listing the
expiration dates of the emergency drugs and supplies;
(c) Listing the name or initials of the
pharmacist who checked the emergency drugs and supplies; and
(d) Highlighting the expiration date of the
medication with the shortest expiration date;
(6) When the emergency drugs and supplies are
contained within an emergency cart, the pharmacist checking the emergency cart
shall ensure that the exterior of the cart is labeled with the:
(a) Contents of the emergency cart;
and
(b) Name or initials of the
pharmacist; and
(7) The
director of pharmacy or designee shall ensure that repackaged drugs contained
in emergency drugs and supplies are labeled:
(a) In accordance with Regulation .10 of this
chapter; and
(b) With other
information as may be required by the medical staff.
D. Upon notification that
emergency drugs and supplies have been opened, a pharmacist or registered
pharmacy technician shall:
(1) Restock the
emergency drugs and supplies; or
(2) Provide a replacement supply.
E. The director of pharmacy or
designee shall ensure:
(1) That the expiration
date of emergency drugs and supplies is the earliest date of expiration of any
drug supplied; and
(2) Before the
expiration date, the pharmacist or designee shall replace the expired drug and
relabel the emergency drugs and supplies as provided in §C(5) of this
regulation.