Hospital Regulations

Question 1

General Guidelines for Hospital Pharmacies

Answer 1

-directed by a licensed pharmacist
(in the absence of a pharmacist, the dispensing of drugs shall be limited to emergencies and under the direct supervision of the practitioner)

-institution may not be considered for a pharmacy permit unless it is open for a min of 20 hrs a week
-hospital pharmacies are primarily inspected by the DOH, but may be inspected by the Board of Pharmacy

Question 2

Pharmacy and Therapeutics Committee (P&T)

Answer 2

-must include: physicians, nurses and pharmacists
-meet quarterly, record its proceedings and repost to the medical staff
-assist in formulation of broad professional polices regarding the evaluation, appraisal, selection, procurement, storage, distribution, use and safety procedures relating to the use of drugs in the hospital

Question 3

What are the specific functions of the P&T Committee?

Answer 3

-Serve as an advisory group to medical staff and pharmacist on the choice of drugs
-Develop and review periodically a formulary
-Recommend standards regarding the use and control of investigational drugs
-Recommend standards concerning research in the use of recognized drugs
-Evaluate clinical data concerning new drugs or preparations
-Make recommendations on drugs stocked on the nursing unit floors,
-Establish procedures which will prevent unnecessary duplication in stocking drugs
-Make recommendations concerning drugs that need automatic stop orders
-Make recommendations regarding proper P&P on the administration of drugs

Question 4

What are the requirements of Pharmacy Facilities in a Hospital?

Answer 4

-maintain a supply of drug that is the same as in the PA Pharmacy Regulation
-any area where drugs are stored must be checked and all floor stocks shall be controlled by the pharmacist
-space and sanitary reqs
-special locked storage space shall be provided to meet the reqs for storage of CSs, alcohol and other prescribed drugs

Question 5

What are the reqs of record keeping in Hospital Pharmacies?

Answer 5

-records for drugs dispensed from the pharmacy
-oral orders shall be accepted only under urgent circumstances when it is impractical for the orders to be given in written manner
-medical staff by laws shall specify personnel who are qualified to accept oral orders, to include the ability of pharmacists to accept and transcribe oral orders pertaining to drugs
- copies of records of all AE reactions and drug sensitivities shall be maintained for 2 yrs

Question 6

What does the oral order have to include in a hospital pharmacy?

Answer 6

-date
-time
-full sig of the person taking the order
–> shall be countersigned by the practitioner within 24 hrs

Question 7

What policies and procedures need to be developed for admin of dangerous drugs in hospital pharmacies?

Answer 7

dangerous drugs = CS, sedatives, anticoagulants, abx, oxytocin’s, and corticosteroids

-automatic stop orders: establish them for dangerous drugs not specifically prescribed as to time ot number the doses
-the prescriber shall be notified according to hospital policies and procedures within 48 hrs before an order to automatically stopped

Question 8

What are the Emergency Pharmaceutical services reqs in hospital pharmacies?

Answer 8

-secure emergency med kit shall be kept and under the control of either the pharmacy, a practitioner licensed to prescribe/dispense or during emergency periods: a staff member designated by the chief executive officer