Or. Admin. Code § 855-041-6305

Current through Register Vol. 63, No. 12, December 1, 2024

Section 855-041-6305 - Night Cabinet

(1) If a night cabinet is used, the following procedures must be followed:

(a) The cabinet or other enclosure located outside the pharmacy must be secure from unauthorized access;

(b) Only one authorized registered nurse on a shift may have access to the night cabinet and may remove drugs. Such nurse must be designated in writing by the appropriate committee of the hospital and prior to being given access to the night cabinet, must receive appropriate training in the proper procedures for access, removal of drugs, and recordkeeping;

(c) The PIC or designee must give this training, and must require, at a minimum, the following procedures:

(A) A drug may only be removed from the night cabinet on a practitioner's written order or a verbal order that has been reduced to writing;

(B) A copy of the practitioner's order must be left in the night cabinet for the pharmacist to verify for accuracy. Both the nurse supervisor and the verifying pharmacist must initial the order.

(2) In conjunction with the appropriate hospital committee, the CPO must develop an inventory of those drugs to be included in each cabinet and establish procedures to ensure that:

(a) Drugs are available and labeled as required by these rules;

(b) Only prepackaged drugs are placed in the cabinet;

(c) Quantities do not exceed those reasonable for immediate therapeutic requirements;

(d) Whenever a cabinet has been accessed, a written record is kept of the drug order and certification of the drug use;

(e) Controlled substances are kept securely and are accounted for using a reconciled perpetual inventory;

(f) An audit of controlled substances in the cabinet is conducted at least once per month. If a tamper-evident seal system is not used, a quality assurance program must be in place to identify any diversion.

Or. Admin. Code § 855-041-6305

BP 3-2010, f. 4-29-10, cert. ef. 4-30-10

Stat. Auth.: ORS 689.205

Stats. Implemented: ORS 689.155 & 689.605