Section R9-10-218. Pharmaceutical Services

An administrator shall ensure that:

1.        Pharmaceutical services are provided under the direction of a pharmacist according to A.R.S. Title 36, Chapter 27;

A.R.S. Title 32, Chapter 18; and 4 A.A.C. 23;

2.        A copy of the pharmacy license is provided to the Depart- ment for review upon the Department's request;

3.        A committee, composed of at least one physician, one pharmacist, and other personnel members as determined by policies and procedures, is established to:

a.         Develop a drug formulary,

b.        Update the drug formulary at least once every 12 months,

c.         Develop medication usage and medication substitu- tion policies and procedures, and

d.        Specify which medications and medication classifi- cations are required to be automatically  stopped after a specified time period unless the ordering medical staff member specifically orders otherwise;

4.        An expired, mislabeled, or unusable medication is dis- posed of according to policies and procedures;

5.        A medication administration error or an adverse reaction is reported to the ordering medical staff member or the medical staff member’s designee;

6.        A pharmacy medication dispensing error is reported to the pharmacist;

7.        In a pharmacist’s absence, personnel members designated by policies and procedures have access to a locked area containing a medication;

8.        A medication is maintained at temperatures recom- mended by the manufacturer;

9.        A cart used for an emergency:

a.         Contains  medication,  supplies,  and  equipment  as specified in policies and procedures;

b.        Is available to a unit; and

c.         Is sealed until opened in an emergency;

10.     Emergency cart contents and sealing of the emergency cart are verified and documented according to policies and procedures;

11.     Policies and procedures specify individuals who may:

a.         Order medication, and

b.        Administer medication;

12.     A medication is administered in compliance with an order;

13.     A medication administered to a patient is documented as required in R9-10-213;

14.     If pain medication is administered to a patient, documen- tation in the patient's medical record includes:

a.         An assessment of the patient’s pain before adminis- tering the medication, and

b.        The effect of the pain medication administered; and

15.     Policies and procedures specify a process for review through the quality management program of:

a.         A medication administration error,

b.        An adverse reaction to a medication, and

c.         A pharmacy medication dispensing error.

Historical Note

Adopted effective February 23, 1979 (Supp. 79-1). Sec- tion repealed; new Section made by final rulemaking at 8

A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Section R9-10-218 renum- bered to R9-10-219; new Section R9-10-218 renumbered from R9-10-217 and amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).