Oklahoma Administrative Code
Title 535 - Oklahoma State Board of Pharmacy
Chapter 15 - Pharmacies
Subchapter 5 - Hospital Pharmacies
Section 535:15-5-8 - Absence of pharmacist

Universal Citation: OK Admin Code 535:15-5-8

Current through Vol. 41, No. 13, March 15, 2024

During such times as a hospital pharmacy may be unattended by a registered pharmacist, arrangements shall be made in advance by the Director of Pharmacy for provision of drugs to the medical staff and other authorized personnel of the hospital facility by use of night cabinets and in emergency circumstances, by access to the pharmacy. A pharmacist must be "on call" during all absences. Written policies and procedures shall be established to implement the requirements of this section and shall be available for Board review.

(1) Night cabinets. IF NIGHT CABINETS ARE USED THE FOLLOWING SHOULD PREVAIL: In the absence of a registered pharmacist, controlled drugs shall be kept in locked cabinet(s) or other enclosure(s) constructed and located outside of the pharmacy area, to which only specifically authorized personnel may obtain access by key or combination, and which is sufficiently secure to deny access to unauthorized person by force or otherwise. The Director shall, in conjunction with the appropriate committee of the hospital facility, develop inventory listings of those drugs to be included in such cabinet(s) and shall insure that:

(A) such drugs available therein are properly labeled;

(B) only prepackaged drugs are available therein, in amounts sufficient for immediate therapeutic requirements;

(C) whenever access to such cabinet(s) shall have been gained, written physician's orders and proofs of use, if applicable, are provided; and,

(D) proper inventories and a complete review of all activity concerning such cabinet(s) are conducted no less than once per month.

(2) Access to pharmacy. Whenever any 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 in accordance with the requirements of this paragraph. One supervisory nurse and only one in any given shift is responsible for removing drugs therefrom. The responsible nurse may, in time of emergency, delegate this duty to another nurse. The responsible nurse shall be designated by position in writing by the appropriate committee of the hospital facility, and shall, prior to being permitted to obtain access to the pharmacy, receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training shall be conducted by the Director of Pharmacy, or a pharmacist designee. Access to the pharmacy as described above shall require, at a minimum, the following records and procedures:

(A) a record of the removal of any drug from the pharmacy by an authorized nurse on a suitable form showing patient name, room number, name of drug, strength, amount, date, time and signature of nurse; and,

(B) such form shall be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly.

Amended at 11 Ok Reg 3431, eff 6-27-94; Amended at 18 Ok Reg 2738, eff 7-1-01

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