Section 11-93-28 - Pharmaceutical services(a) The hospital shall either employ sufficient licensed pharmacists or have a written contract with a licensed pharmacist to provide services necessary to meet patients' medication needs, to provide consultation on methods and procedures for ordering, monitoring and assessment, storage, administration, disposal, and record keeping of pharmaceuticals and drugs.(b) There shall be a current pharmacy policy manual developed and approved by the pharmacist, physicians, and professional nursing staff which: (1) Includes policies, procedures, functions, and responsibilities of the pharmacy service.(2) Provides for regular periodic revision.(3) Governs the safe administration, preparation, handling and storage of all drugs.(4) Includes policies regarding self-administration of drugs.(5) Includes a formulary appropriate to the hospital.(c) Medications administered to a patient shall be ordered either in writing or verbally by an individual so authorized by hospital policy. (1) Verbal orders for prescription drugs shall be given only by a physician and shall be accepted only by a licensed nurse, pharmacist, or physician.(2) All verbal or telephone orders for medication shall be recorded and signed by the person receiving them and shall be countersigned by the attending physician within twenty-four hours.(d) Each drug, dose and dosage route shall be identified immediately prior to administration and each patient receiving the ordered drug shall be identified immediately prior to administering of the drug.(e) Medication shall not be used for any patient other than the one for whom it was prescribed.(f) Only appropriately licensed and trained staff shall be allowed to administer drugs and shall be responsible for proper recording of the medication including the route of administration. Medication errors and drug reactions shall be recorded in the patient's chart, and reported immediately to a physician. A report shall be prepared and shall be submitted promptly to the administrator or the designated representative.(g) Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. (1) All drugs shall be kept under lock and key except when authorized personnel are in attendance.(2) All security requirements of federal and state laws shall be satisfied as they refer to storerooms and pharmacies.(3) Drugs intended to be used only externally, and drugs taken internally shall be stored in separate well-marked cabinets or drawers, at all locations.(4) Medications that are stored in a refrigerator, which contains things other than drugs, shall be stored separately in a locked container.(5) If there is a drug storeroom separate from the pharmacy, there shall be a perpetual inventory of receipts and issues of all drugs by such storerooms.(6) Discontinued and outdated drugs, and containers with worn, illegible, or missing labels, and drugs dispensed to a specific patient and left on the floor after discharge of the patient, shall be returned to the pharmacy or drug room for proper disposition.(7) There shall be automatic stop order policies.(8) There shall be a drug recall procedure that can be readily implemented.(9) Only specifically authorized personnel shall have access to locked compartments, drawers, and cabinets.(10) In no case shall chemical agents not intended for patient use be stored in the same cabinets or drawers with medications.[Eff. 3/3/86; am and ren AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11) (Imp: HRS §§ 321-9, 321-11)