(a) The PIC shall be responsible for the preparation, sterilization, labeling, and dispensing of parenteral medications prepared within the institutional facility and shall participate in the education and training, including the provision of appropriate incompatibility information, of all personnel involved in the preparation of parenteral medications.
(b) If intravenous admixtures are prepared within the institutional facility, the institutional pharmacy shall have adequate equipment, personnel, and space for such preparation. The compounding and labeling of intravenous admixtures, including all total parenteral nutrition, shall be performed by, or under, the direct supervision of a pharmacist; however, if twenty-four hour (24-hour) pharmacy service is not provided at the institutional facility, the PIC shall establish written policies and procedures to be followed in the preparation of intravenous admixtures when the institutional pharmacy is closed or in emergency situations.
(c) All admixtures shall be labeled with a distinctive supplementary label, indicating the name and amount of drug added, date and time of addition, beyond use date, and rate of administration, and the name or identification code of the person adding the drug.
(d) The PIC shall be responsible for removing concentrated electrolytes (including, but not limited to: potassium chloride, potassium phosphate, sodium chloride greater than 0.9%) from patient care areas and limiting their access to pharmacists. If twenty-four hour (24-hour) on-call status for pharmacists is not available, the institutional facility must utilize the most trained professional available to process concentrated electrolytes. Training in the safe use of concentrated electrolytes should be conducted by the institutional pharmacy for non-pharmacist staff with access to concentrated electrolytes. Evidence of training will be documented and retrievable, and the institutional facility will have policies and procedures that detail this process. Premixed large volume intravenous solutions containing electrolytes and premixed potassium bolus doses will be used whenever possible.
059-12 Wyo. Code R. § 12-16