New Mexico Administrative Code
Title 7 - HEALTH
Chapter 7 - HOSPITALS

Universal Citation: 7 NM Admin Code

Current through Register Vol. 35, No. 6, March 26, 2024

A. Organization.

(1) Pharmacy: The hospital pharmacy including pharmaceuticals contained in disaster and emergency caches held by the hospital, shall be supervised by a designated pharmacist-in-charge who is employed part-time or full-time. If employed part-time, the pharmacist shall visit the facility at least every 72 hours.

(2) Other storage: If there is no pharmacy, pre-labeled, prepackaged medications shall be stored in, and distributed from, an automated medication management system, which is under the supervision of the pharmacist-in-charge.

(3) Pharmacist accountability:The pharmacist-in-charge shall have appropriate administrative oversight and shall prepare a pharmacy policy and procedure manual that shall be reviewed and updated at least annually.

B. Facility.

(1) Space and Equipment: The pharmacy shall meet the space and equipment requirements specified by the New Mexico board of pharmacy.

(2) Security: The pharmacist shall control access to the pharmacy and any automated medication system devices. Established procedures shall assure accountability for all doses of drugs removed when the pharmacist is not present. Only a designated licensed nurse may remove drugs from the pharmacy when the pharmacist is not present.

(3) Drug preparation areas: All drug storage and preparation areas within the facility shall be the responsibility of the pharmacist and inspected at least monthly.

(4) Pharmacy policies and procedures should address practices to be followed when compounding, reconstituting, and repackaging medications to assure adherence to professional standards of practice for cleanliness and infection control.

(5) Schedule II controlled substance storage: Schedule II controlled substances that are stored in the pharmacy shall be stored in a separate locked storage.

C. Personnel.

(1) The pharmacist shall be assisted by an adequate number of competent and qualified personnel. Job descriptions for all categories shall be prepared and revised as necessary.

(2) A pharmacist shall be on call during all absences of the designated pharmacist from the facility.

D. Records. Hospital pharmacies shall maintain all dangerous drug distribution records that are required by applicable state and federal laws and regulations, including:

(1) floor stock dangerous drug description records; and

(2) inpatient dangerous drug description records:
(a) schedule II controlled substance distribution records must be kept separate;

(b) schedule III-V controlled substance distribution records must be readily retrievable;

(c) an annual inventory of schedule II-V controlled substances shall be conducted and a record maintained along with the procurement records for these drugs;

(d) when automated drug distribution systems are utilized, they shall produce transaction records that meet the above records keeping requirement;

(e) the pharmacist shall maintain records of quality improvement monitoring of automated drug distribution systems.

E. Other Responsibilities of the Pharmacist.

(1) When limited doses of a drug are removed from the pharmacy when the pharmacist is not present:
(a) the pharmacist shall verify the withdrawal within 72 hours of the withdrawal;

(b) a drug regimen review, pursuant to a new medication order, will be conducted by a pharmacist, either on-site or by electronic transmission, within 24 hours of the new order.

(2) The pharmacist also shall:
(a) provide drug information to staff and patients of the facility;

(b) maintain current drug use reference manuals;

(c) provide and document in-service education to the facility's professional staff;

(d) in conjunction with the practitioners, nurses, and other professional staff, review significant adverse drug reactions; and

(e) review each medication order for safety and appropriateness and communicate with the prescribers when indicated.

Disclaimer: These regulations may not be the most recent version. New Mexico 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.
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