Rule 480-8-.04 - Absence of PharmacistThe following regulations shall be followed in the absence of a Pharmacist:
(a) General. When a registered pharmacist is not physically present in the prison clinic pharmacy, written policies and procedures shall be prepared in advance by the Director of Pharmacy for the provision of drugs to the medical staff and other authorized personnel of the prison clinic by use of night cabinets and/or by access to the pharmacy.(b) Night cabinets. Access to drugs, in the absence of a licensed pharmacist, shall be by locked cabinet(s) or other enclosure(s) constructed and located outside of the pharmacy area to which only specifically authorized personnel as indicated by written policies and procedures may obtain access by key or combination, and which is sufficiently secure to deny access to unauthorized persons. The Director of Pharmacy shall, in conjunction with the appropriate committee of the prison clinic, develop inventory listings of those drugs to be included in such cabinet(s) and shall insure that:1. Such drugs are available therein, properly labeled, with drug name, strength, lot number and expiration date;2. Only prepackaged drugs are available therein, in amounts sufficient for immediate therapeutic requirements;3. Whenever access to such cabinet(s) shall have been gained, written physician's orders and proofs of use for controlled substances are provided;4. All drugs therein are inventoried no less than once per week. A system of accountability must exist for all drugs contained therein; and,5. Written policies and procedures are established to implement the requirements of the subsection.(c) Access to pharmacy. Whenever any drugs are not available from floor supplies of 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 pursuant to the physician's order and the requirements of this subsection. Only one designated, licensed medical staff member (R.N., L.P.N. or Clinic Associate) in any given 8-hour shift may have access to the pharmacy and may remove drugs from there. Such licensed medical personnel shall be designated in writing by the Director of Pharmacy of the prison clinic 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 given by the Director of Pharmacy, who shall require, at a minimum, the following records and procedures:1. Removal of any drug from the pharmacy by an authorized medical staff member must be recorded on a suitable form showing name of drug, strength, amount, date, time and signature of the authorized medical staff member.2. The container from which the drug is removed shall be placed conspicuous location so as to be promptly reviewed and inspected by a pharmacist coming on duty.(d) Emergency kits/crash carts. Drugs may be provided for use by authorized personnel by emergency kits, provided such kits meet the following requirements: 1. Emergency kit drugs defined. Emergency kit drugs are those drugs which may be required to meet the immediate therapeutic needs of patients and which are not available from any other authorized source in sufficient time to prevent risk or harm to patients;2. Drugs included. The Director of Pharmacy and the medical staff of the prison clinic shall jointly determine the drugs, by identity and quantity to be included in emergency kits;3. Storage. Emergency kits shall be stored in limited access areas and sealed to prevent unauthorized access, and to insure a proper environment for preservation of the drugs contained.4. Labeling--exterior. The exterior of emergency kits shall be labeled so as to clearly and unmistakably indicate that it is an emergency drug kit and is for use in emergencies only. In addition, a listing of the drugs contained therein, including name, strength, quantity, and expiration date of the contents shall be attached. Nothing in this section shall prohibit another method of accomplishing the intent of this section, provided such method is approved by the Board and proper documentatoin of such approval is maintained;5. Labeling--interior. All drugs contained in emergency kits shall be labeled in accordance with such State and Federal Laws and Regulations which pertain thereto; and shall also be labeled with such other and further information as may be required by the medical staff of the prison clinic to prevent misunderstanding or risk or harm to the patients;6. Removal of drugs. Drugs shall be removed from emergency kits only pursuant to a valid physician's order, by authorized medical personnel, or by a pharmacist of the institutional facility;7. Notification. Whenever an emergency kit is opened, the pharmacy shall be notified; and the pharmacy shall re-stock the kit within a reasonable time (no later than a Pharmacist's next visit to institution) so as to prevent risk or harm to patients. In the absence of a pharmacist, at least one emergency kit will be made available for exchange. In the event the kit is opened in an unauthorized manner, the pharmacy and other appropriate personnel of the facility shall be notified;8. Inspections. Each emergency kit shall be opened and its contents inspected by the pharmacy at least once every ninety (90) days. Upon completion of inspection, the emergency kit shall be re-sealed.9. Policies and Procedures. The director of Pharmacy shall, in conjunction with the medical staff of the prison clinic, develop and implement written policies and procedures to insure compliance with the provisions of this subsection.(e) Authoritative, current antidote information as well as the telephone number of the regional poison control information center should also be readily available in areas outside the pharmacy where emergency kits are stored.Ga. Comp. R. & Regs. R. 480-8-.04
O.C.G.A. Section 26-4-37, 26-4-27, 26-4-28, 26-4-110.
Original Rule entitled "Absence of Pharmacist" adopted. F. Dec. 27, 1985; eff. Jan. 16, 1986.Repealed: New Rule, same title adopted. F. Sept. 28, 2001; eff. Oct. 18, 2001.