Section 61-07-01-05 - Absence of pharmacist1.General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance by the director for the provision of drugs to the medical staff and other authorized personnel of the hospital, by use of night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy. A pharmacist must be available for consultation during all absences; this protocol can be accomplished by telephone.2.Night cabinets. If night cabinets are used, the following should prevail: absence of a pharmacist, must be by locked cabinets or other enclosures constructed and located outside of the pharmacy area, to which only specifically authorized personnel may obtain access by key or combination, and which is sufficiently secure to deny access to unauthorized persons by force or otherwise. The director shall, in conjunction with the appropriate committee of the hospital, develop inventory listings of those drugs to be included in such cabinets and shall ensure that: a. Such drugs are available therein, properly labeled.b. Only prepackaged drugs are available therein, in amounts sufficient for immediate therapeutic requirements. c.Whenever access to such cabinets shall have been gained, written physician's orders and proofs of use, if applicable, are provided.d. Written policies and procedures are established to implement the requirements of this subsection.3.Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training must be given by the director of pharmacy, who shall require, at a minimum, the following records and procedures:a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse.b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly; or, in the case of a unit dose, place an additional dose of the drug, or the box, on the form.4.Emergency kits. Emergency drugs, as approved by the medical staff, must be in adequate and proper supply in the pharmacy and in designated hospital areas. The pharmacist is responsible both for the contents of emergency medication carts, kits, and for the inspection procedure to be used.N.D. Admin Code 61-07-01-05
General Authority: NDCC 28-32-02
Law Implemented: NDCC 43-15-10(9), 43-15-10(12), 43-15-10(14)