Okla. Admin. Code § 535:15-6-10

Current through Vol. 42, No. 4, November 1, 2024

Section 535:15-6-10 - Access to drugs in absence of PIC or drug room supervisor

(a)Absence of the PIC or the drug room supervisor. Advance arrangements shall be made for provision of drugs to the medical staff and other authorized personnel of the hospital facility by use of night cabinets and in emergency circumstances, by access to the drug room by authorized personnel during such times as the drug room may be unattended.

(b)Night cabinets.IF NIGHT CABINETS ARE USED THE FOLLOWING SHOULD PREVAIL:

(1) In the absence of a pharmacist (D.Ph.), a supply of controlled dangerous substances may be kept in locked cabinet(s) or other enclosure(s) constructed and located outside of the hospital drug room area, to which only specifically authorized personnel may obtain access by key or combination, and which is sufficiently secure to deny access to an unauthorized person by force or otherwise.

(2) The PIC shall, in conjunction with the appropriate committee of the hospital facility, develop inventory listings of those drugs to be included in such cabinet(s) and shall insure that:

(A) Such drugs, available therein, are properly labeled;

(B) Only prepackaged drugs are available therein, in amounts sufficient for immediate therapeutic requirements;

(C) Whenever access to such cabinet(s) shall have been gained, written ALI practitioner's orders and proofs of use, if applicable, are provided;

(D) A method of documenting responsibility for the key(s) at all times, and their transfer from one authorized person to another, is established;

(E) All drugs therein are monitored weekly, and discrepancies are reported in the PIC's report.

(F) A complete review of all activity concerning such cabinet(s) is conducted no less than once per month; and,

(G) Written policies and procedures are established to implement the requirements of this paragraph.

(c)Access to drug room.Whenever any drug is not available from floor supplies or 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 drug room in accordance with the requirements of this paragraph.

(1) One supervisory registered professional nurse and only one in any given shift is responsible for removing drugs from the hospital drug room. The responsible nurse may, in time of emergency, delegate this duty to another nurse.

(2) The responsible nurse shall, prior to being permitted to obtain access to the drug room, be designated by position in writing by the appropriate committee of the hospital facility; and shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required from the PIC.

(3) Such education and training shall be given by the PIC.

(4) The PIC shall require, at a minimum, the following records and procedures:

(A) The removal of any drug from the hospital drug room by an authorized licensed nurse must be recorded on a suitable record showing patient name, room number, name of drug, strength, amount, date, time and signature of nurse; and

(B) The drug room supervisor or the pharmacist shall properly and promptly check such record.

Okla. Admin. Code § 535:15-6-10

Added at 20 Ok Reg 2479, eff 1-1-04

Amended by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015.