.08 Responsibilities of Director of Pharmacy.

The director of pharmacy or designee shall:

A. Be responsible for the safe and efficient dispensing, control, security, and accountability of drugs;

B. Work in cooperation with the other professional staff of the institutional facility with respect to the duties listed in this regulation and in ordering, administering, and controlling drug products and materials, including prescription blanks;

C. Supervise the preparation of parenteral and other medications compounded within the institutional facility;

D. Provide written policies and procedures to hospital professional and technical staff with regard to admixtures prepared within the institution outside of the institutional pharmacy including, but not limited to:

(1) Establishing policies and procedures for preparation and handling of the admixtures; and

(2) Providing incompatibility information with respect to the admixtures;

E. Recommend specifications for procurement, storage and disposal of drugs, chemicals, and biologicals administered to patients to the appropriate committee of the institutional facility as determined by the governing body;

F. Participate in the development of a formulary for the facility;

G. Establish procedures for the development of a standard format and ongoing procedures for checking the accuracy and placement of labels on medications throughout the institution;

H. Maintain and make available an inventory of antidotes and other emergency drugs, both in the pharmacy and in patient care areas, as well as:

(1) Current antidote information;

(2) Telephone numbers of a regional poison information center;

(3) Other emergency assistance organizations; and

(4) Such other materials and information as may be considered necessary by the governing body of the institutional facility;

I. Maintain records of transactions of the institutional pharmacy as may be required by applicable law and as may be necessary to maintain accurate control and accountability for pharmaceuticals;

J. Participate in those aspects of the institutional facility's quality assurance and improvement program which relate to medication safety and pharmaceutical utilization and effectiveness;

K. Participate in teaching or research programs, or both, in the institutional facility as required;

L. Implement the policies, procedures, and decisions of the governing body of the institutional facility;

M. Ensure that a system is in place that provides a safe, secure, and efficient distribution system for pharmaceutical products within the facility;

N. Ensure that the institutional pharmacy meets inspection and other requirements of Health Occupations Article, Title 12, Annotated Code of Maryland, and these regulations;

O. Develop and implement policies and procedures to ensure that discontinued and outdated drugs and drug containers with worn, illegible, or missing labels are returned to the pharmacy for proper disposition;

P. Establish policies and procedures for identification, handling, storage, and disposition of medications brought into the institution by the patients;

Q. Conduct an on-going plan for a quality assurance program that will review and evaluate pharmaceutical services and recommend improvements in these services;

R. Establish policies and procedures for identification and handling of investigational drugs that include the provision of pharmacologic and toxicologic information to the medical and nursing staff according to institutional policies ;

S. Arrange for the inspection of drug storage areas throughout the institution on a monthly basis and maintain written records of these reviews; and

T. Participate in developing and monitoring the policies and procedures pertaining to:

(1) Administration of drugs at an institutional facility to ensure that only authorized individuals administer drugs; and

(2) Self-administration of drugs not on the hospital formulary by patients to ensure that the:

(a) Administration occurs in accordance with procedures established by the appropriate committee of the institution; and

(b) That the self-administration is ordered by an authorized prescriber.