10.34.03.11

.11 Drug Dispensing — Emergency Supplies and Procedures.

A. The director of pharmacy shall participate in the development and maintenance of the formulary for emergency drugs and supplies that are maintained throughout the institutional facility.

B. The director of pharmacy or designee shall, in conjunction with the medical staff of the institutional facility, develop and implement written policies and procedures to ensure compliance with the provisions of this regulation.

C. The institutional pharmacy shall furnish emergency drugs and supplies only if:

(1) The emergency drugs and supplies are stored in an environment which:

(a) Maintains the integrity of the drugs; and

(b) Provides accessibility only to authorized personnel;

(2) The institution follows a policy that drugs will be dispensed from the emergency drugs and supplies formulary only upon written or verbal order by an authorized prescriber;

(3) The emergency drugs and supplies are stocked and maintained in a manner that complies with the standards of applicable State law;

(4) The emergency drugs and supplies are:

(a) Stored and secured:

(i) With a tamper evident seal; or

(ii) Via electronic means; and

(b) Kept in a secure area;

(5) The emergency drugs and supplies are labeled as follows:

(a) Clearly indicating that the emergency drugs and supplies are for use in emergencies only;

(b) Listing the expiration dates of the emergency drugs and supplies;

(c) Listing the name or initials of the pharmacist who checked the emergency drugs and supplies; and

(d) Highlighting the expiration date of the medication with the shortest expiration date;

(6) When the emergency drugs and supplies are contained within an emergency cart, the pharmacist checking the emergency cart shall ensure that the exterior of the cart is labeled with the:

(a) Contents of the emergency cart; and

(b) Name or initials of the pharmacist; and

(7) The director of pharmacy or designee shall ensure that repackaged drugs contained in emergency drugs and supplies are labeled:

(a) In accordance with Regulation .10 of this chapter; and

(b) With other information as may be required by the medical staff.

D. Upon notification that emergency drugs and supplies have been opened, a pharmacist or registered pharmacy technician shall:

(1) Restock the emergency drugs and supplies; or

(2) Provide a replacement supply.

E. The director of pharmacy or designee shall ensure:

(1) That the expiration date of emergency drugs and supplies is the earliest date of expiration of any drug supplied; and

(2) Before the expiration date, the pharmacist or designee shall replace the expired drug and relabel the emergency drugs and supplies as provided in §C(5) of this regulation.