Section R4-23-654. Absence of Pharmacist

A.      If a pharmacist will not be on duty in the hospital, the Director of Pharmacy or pharmacist-in-charge shall arrange, before the pharmacist’s absence, for the medical staff and other autho- rized personnel of the hospital to have access to drugs in the remote drug storage area defined in R4-23-110 or in the hospi- tal pharmacy if a drug is not available in a remote drug storage area and is required to treat the immediate needs of a patient. A pharmacist shall be on-call during all absences.

B.       If a pharmacist will not be on duty in the hospital pharmacy, the Director of Pharmacy or pharmacist-in-charge shall arrange, before the pharmacist’s absence, for the medical staff and other authorized personnel of the hospital to have tele- phone access to an on-call pharmacist.

C.      The hospital pharmacy permittee shall ensure that the hospital pharmacy is not without a pharmacist on duty in the hospital for more than 72 consecutive hours.

D.      Remote drug storage area. The Director of Pharmacy or phar- macist-in-charge shall, in consultation with the appropriate committee of the hospital:

1.        Develop and maintain an inventory listing of the drugs to be included in a remote drug storage area; and

2.        Develop, implement, review, and revise in the same man- ner described in R4-23-653(A) and comply with policies and procedures that ensure proper storage, access, and accountability for drugs in a remote drug storage area.

E.       Access to hospital pharmacy. If a drug is not available from a remote drug storage area and the drug is required to treat the immediate needs of a patient whose health may be compro- mised, the drug may be obtained from the hospital pharmacy according to the requirements of this subsection.

1.        The Director of Pharmacy or pharmacist-in-charge shall, in consultation with the appropriate committee of the hos- pital, develop, implement, review, and revise in the same manner described in R4-23-653(A) and comply with pol- icies and procedures to ensure that access to the hospital pharmacy during the pharmacist’s absence conforms to the following requirements:

a.         Access is delegated to only one supervisory nurse in each shift;

b.        The policy and name of supervisory nurse is com- municated in writing to the medical staff of the hos- pital;

c.         Access is delegated only to a nurse who has received training from the Director of Pharmacy, pharmacist-

in-charge, or Director’s designee in the procedures required for proper access, drug removal, and recordkeeping; and

d.        Access is delegated by the supervisory nurse to another nurse only in an emergency.

2.        If a nurse to whom authority is delegated to access the hospital pharmacy removes a drug from the hospital phar- macy, the nurse shall:

a.         Record the following information on a form or by another method approved by the Board or its desig- nee:

i.         Patient’s name;

ii.        Drug name, strength, and dosage form;

iii.      Quantity of drug removed; and

iv.       Date and time of removal;

b.        Sign or initial, if a corresponding signature is on file in the hospital pharmacy, the form recording the drug removal;

c.         Attach the original or a direct copy of the medication order for the drug to the form recording the drug removal; and

d.        Place the form recording the drug removal conspicu- ously in the hospital pharmacy.

3.        Within four hours after a pharmacist returns from an absence, the pharmacist shall verify all records of drug removal that occurred during the pharmacist’s absence according to R4-23-653(E).

Historical Note

Former Rules 6.7410, 6.7420, 6.7430, 6.7440, 6.7450,

and 6.7460; Amended subsection (A) effective Aug. 9, 1983 (Supp. 83-4). Section repealed, new Section adopted effective February 7, 1990 (Supp. 90-1).

Amended by final rulemaking at 8 A.A.R. 4902, effective January 5, 2003 (Supp. 02-4). Amended by final

rulemaking at 10 A.A.R. 1192, effective May 1, 2004 (Supp. 04-1). Amended by final rulemaking at 12 A.A.R.

3032, effective October 1, 2006 (Supp. 06-3).