The pharmacist in charge or designee, in conjunction with appropriate committees of the facility, shall be responsible for approving policies for the distribution and control of drugs within the facility. The process shall be established to provide for the safe and efficient distribution of drugs and for the provision of pharmaceutical care, and shall include but not be limited to:
(1) A drug dispensed from the pharmacy for subsequent administration to a patient shall be appropriately identified with the name and location of the patient and the name and strength of the drug.(2) The pharmacist in charge is responsible for the development and maintenance of an audit trail on drugs dispensed.(3) The prescription order shall be recorded on a patient medication profile that will be maintained during the patient's treatment. This profile shall include the date of the prescription order, the name and dosage form of the drug and the dose and administration frequency.(4) The facility distribution system may be based on a combination of processes that will ensure compliance with federal and state guidelines such as emergency kits/crash carts, floorstock systems, automated dispensing devices, medication carts, and/or after-hours procedures for pharmacy site access.(5) Upon request, the Board may waive selected portions of these requirements so long as any waiver granted is consistent with the Board's authority under Tenn. Code Ann. Title 63, Chapters 1 and 10, and Tenn. Code Ann. Title 4, Chapter 5.Tenn. Comp. R. & Regs. 1140-04-.05
Original rule filed February 7, 1983; effective March 9, 1983. Amendment to rule filed November 16, 1992; effective January 8, 1993. Repeal and new rule filed May 11, 1998; effective July 25, 1998. Amendments filed November 22, 2016; effective 2/20/2017.Authority: T.C.A. §§ 63-10-204, 63-10-304, 63-10-404(11), (14), and (27), and 63-10-504(b)(1) and (2).