Oklahoma Administrative Code
Title 535 - Oklahoma State Board of Pharmacy
Chapter 15 - Pharmacies
Subchapter 6 - Hospital Drug Room
Section 535:15-6-5 - Drug room and PIC responsibilities and duties

(1) Written procedures. The hospital drug room and PIC shall establish written procedures for the safe and efficient acquisition, distribution, and utilization of all medicine products with any of the Federal legends such as "RX only" and medications administered or distributed in the hospital system. A current copy of such procedures shall be available for review by the Board.

(2) General Responsibility. The hospital drug room and PIC shall be responsible for the safe and efficient monitoring, distribution, control, purchasing, acquisition and accountability of all drugs including but not limited to Federal legend drug products used in diagnostic procedures, I.V. fluids, or contained in supply kits excluding blood bank products and reagents controlled by the laboratory. The other professional staff of the hospital facility shall cooperate with the pharmacist in meeting this responsibility.

(3) Confidentiality. The hospital drug room and PIC shall have responsibility for establishing policies for the security and integrity of any patient information, confidential and non-confidential, and must abide by all relevant State and Federal regulations applicable to the hospital system.

(4) Adverse Drug Events Program. The hospital drug room and PIC shall develop and maintain a program to monitor the actual and potential adverse drug events including pharmacist interventions, medication errors, and adverse drug reactions for all medications utilized in the hospital to include system wide programs if an integrated system is involved. Records indicating the tracking, review, and outcome of the Adverse Drug Events shall be kept current and available for Board inspection.

(5) Investigational drug programs. The PIC shall establish a policy for investigational drug use.

(6) Review of medication orders. The PIC shall cause medication orders to be reviewed by a 100 pharmacist in a timely manner.

(7) Pharmacists Visits. The hospital drug room and PIC shall cause and document a minimum of 52 routine in-house visits per year to be made to a hospital with a drug room as required by health department rule OAC 310:667-21-2(a) et seq.

(8) Pharmacy and Therapeutics (P&T) Committee. The PIC shall be a participating member in the Pharmacy and Therapeutics Committee.

(9) Effective Controls. The hospital drug room and PIC shall establish and maintain effective controls against the diversion of prescription drugs into other than legitimate medical, scientific, or industrial channels as provided by federal, state or local laws or rules.

(1) The training duties of the PIC are:

(2) Repackaging drug products including unit dose.

(3) Establishing procedures for procurement of all medicines used within the hospital system subject to approval of the medical and professional staff.

(4) Participating in the development and maintenance of a formulary for use within the hospital system.

(5) Maintaining and making available a sufficient inventory of medicines including antidotes and other emergency drugs approved by the medical and professional staff, for use within the hospital facility. In addition, current references, antidote information, and telephone numbers of regional reference centers such as Poison Centers and Drug Information Centers shall be maintained and readily available throughout the hospital.

(6) Maintaining oversight of the records of all transactions of the drug room required by applicable local, state, and federal law, and necessary to maintain accurate control and accountability for all medications.

(7) Participating in those aspects of the hospital facility's patient care evaluation programs that relate to medicine utilization and effectiveness.

(8) Cooperating fully with teaching and/or research programs in the hospital facility, if any.

(9) Implementing the policies and decisions of the appropriate committees of the medical and professional staff that deal with drug distribution.

(10) Meeting all inspection and other requirements of the Oklahoma Pharmacy Act, and those rules and regulations governing the practice of pharmacy within a hospital facility.

(11) Establishing guidelines for the safe and effective distribution of medicines intended for floor stock, and their subsequent administration.