SECTION 310:667-21-2. Personnel

(a)   Pharmacist director or consultant. The pharmacist director or consultant shall be responsible for all drugs that come into the hospital. The pharmacist shall be trained in the specialized functions of hospital pharmacy and be responsible to the administrator for developing, supervising, and coordinating all activities of the pharmacy or drug room, whether on a full-time or consultant basis. The consultant pharmacist shall visit the hospital a minimum of fifty-two (52) times per year, with no more than five (5) visits in any one month counted toward this total, and shall submit a report outlining issues encountered and decisions made during the visit. The responsibility and authority of the pharmacist shall be clearly defined in a written job description. The responsibilities include but are not limited to:

(1)   Establishes and implements intradepartmental and interdepartmental written policies and procedures regarding methods of reconciliation and control of drugs, including audit trails governing all areas of pharmaceutical services. These policies and procedures shall be in compliance with local, state, and federal laws and current professional principles and practices.

(2)   Establishes liaison with the administrator and the chief of the medical staff regarding written policies and procedures and their interaction and interdependency with the requirements of the medical staff bylaws and rules and regulations, the governing body rules and regulations, and administrative interdepartmental policies.

(3)   Employs an adequate number of pharmacists and other personnel, as required by department activities and services to implement pharmaceutical services.

(4)   Provides drug information services to physicians and licensed independent practitioners, dentists, nurses, and other health care staff.

(5)   Provides poison information services to physicians and licensed independent practitioners, dentists, nurses, and other health care staff.

(6)   Provides inservice training to physicians and licensed independent practitioners, nurses, pharmacy staff, and other personnel as applicable.

(7)   Provides documentation that orientation and staff-development training are provided to pharmacy personnel. Documentation shall include but not be limited to:

(A)   Formal orientation of new personnel to written policies of the department.

(B)   Inservice education and staff development.

(C)   Specialized training in admixture service.

(D)   Outline of program content.

(E)   Signatures of staff attending with title.

(8)   Provides records of tax-free alcohol, investigational drugs, and controlled dangerous drug substances, as required by local, state, and federal laws, rules and regulations.

(9)   Provides reviews of patient drug orders and requisitions to avoid possible errors in medication administration.

(10)   Maintains a stock of drugs, as agreed in the formulary or drug list, for daily and emergency use.

(11)   Develops quality assurance methods to determine that the activities of the department are within the interdepartmental and intradepartmental policies and procedures.

(12)   Reports all deficiencies identified through quality assurance methods and the methods of correction of deficiencies to the chief executive officer, the departmental chief, and/or the pharmacy and therapeutics committee.

(13)   Provides reports of all visits by the consulting pharmacist. The reports include documentation of consultation with the administrator or the administrator's designee. A copy of the consultant's visit reports shall be retained in the drug room.

(14)   Make copies of current policies and procedures available to all appropriate personnel.

(15)   Provides an agreement with other licensed pharmacists for provision of outside pharmacy services in case of emergency.

(b)   Pharmacist. The pharmacist shall provide drugs in conformance with ordering physicians' or practitioners' orders, departmental policy, medical staff bylaws, and local, state, and federal rules and regulations and in accordance with current professional principles and practices. Proof of current licensure shall be available for all pharmacists. Pharmacists who serve as preceptors shall provide the approved preceptorship permit.

(c)   Drug room supervisor. The drug room supervisor shall be a registered pharmacist, registered nurse, or a licensed practical nurse, who shall assist the pharmacist in procuring, receiving, storage, distribution, record keeping, and disposition of drug products and medications. The drug room supervisor shall be designated in writing by the consultant pharmacist and the administrator. All dispensing, compounding, labeling, and repackaging of drugs products shall be under the direct supervision of the pharmacist. The qualifications and duties of the drug room supervisor shall be provided in a written job description.

(d)   Other pharmacy staff. Written job descriptions shall be available and a staff orientation, development, and inservice training program shall be provided to acquaint the staff of the requirements and limitation of their functions in the pharmacy.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-03]