OAR 855-041-6800
Supervision of Consulting Pharmacist

(1)

In a hospital having a drug room and no pharmacy, the drug room must be supervised by a licensed pharmacist who provides his or her services with sufficient professionalism, quality and availability to adequately protect the safety of the patients and to properly serve the needs of the facility. The arrangements for a consulting pharmacist shall be in writing, and shall, at a minimum, provide that:

(a)

The pharmacist is to act in the capacity of a part-time director;

(b)

The pharmacist shall provide on-call service at all times;

(c)

Adequate storage facilities for drugs will be provided; and

(d)

All drugs supplies shall be labeled so as to insure that recalls can be effected and that proper control and supervision of such drugs may be exercised.

(2)

One registered nurse supervisor and only one in any given shift may have access to the drug room and may remove drugs therefrom, except in an emergency situation. In that case, such nurse may designate another licensed nurse to obtain the required drug(s). Any access to the drug room deviating from the requirements of this section must be approved by the Board prior to implementation. The registered nurse supervisor shall be designated in writing by the appropriate committee of the hospital and shall, prior to being permitted to obtain access to the drug room, receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training shall be given by the director of pharmacy, who shall require, at a minimum, the following records and procedures:

(a)

Drugs can only be removed from the drug room on a practitioner’s written order, or verbal order which has been reduced to writing;

(b)

A log of drugs withdrawn from a drug room shall be maintained and initialed by the registered nurse;

(c)

Drugs shall be removed for outpatients only in compliance with section (3) of this rule.

(3)

The consultant pharmacist who is the part-time director of pharmaceutical services shall in concert with the appropriate committee of the hospital medical staff, develop policies and procedures which shall be implemented to provide emergency pharmaceuticals to outpatients during the hours when normal community or hospital pharmacy services are not available. Such policies shall allow the designated registered nurse supervisor to issue medications pursuant to the pharmacist’s standing orders, which shall provide:

(a)

A written order of a practitioner authorized to prescribe a drug is presented;

(b)

The medication is prepackaged by a pharmacist and contains:

(A)

Name, address and telephone number of the hospital;

(B)

Name of drug, strength, and number of units; when a generic name is used, the label shall also contain the name of the manufacturer or distributor;

(C)

Required precautionary information regarding controlled substances;

(D)

Such other and further accessory cautionary information as required for patient safety;

(E)

An expiration date after which the patient should not use the medication.

(c)

No more than a 24-hour supply is provided to the patient, except when the pharmacist has informed the nurse supervisor that normal services will not be available within 24 hours;

(d)

The container is labeled by the nurse supervisor before presenting to the patient, and shows the following:

(A)

Name of patient;

(B)

Directions for use to the patient;

(C)

Date;

(D)

Identifying number;

(E)

Name of prescribing practitioner;

(F)

Initials of the supervisor.

(e)

The original written order by the prescriber is retained for verification by the pharmacist after completion by the nurse supervisor and shall bear:

(A)

Name and address of patient;

(B)

Date of issuance;

(C)

Units issued;

(D)

Initials of supervisor issuing medication.

(f)

The original written order is verified by the pharmacist, initialed, dated, and filed in a separate location for a period of three years for Board inspection;

(g)

The withdrawal of a single dose for immediate administration to the patient need not follow the requirements of subsection (d) of this section.

(4)

Emergency Kits:

(a)

Emergency Kit Drugs Defined. Emergency kit drugs are those drugs which may be required to meet the immediate therapeutic needs of in-patients, and which are not available from any other authorized source in sufficient time to prevent risk of harm to patients by delay resulting from obtaining such drugs from such other source;

(b)

Supplying Pharmacist. All emergency kit drugs shall be prepared by a licensed pharmacist;

(c)

Drugs Included. The director of pharmacy and the medical staff of the hospital shall jointly determine and prepare a list of drugs, by identity and quantity, in amounts sufficient for immediate therapeutic requirements, to be included in emergency kits. Such list of drugs shall be reviewed annually by the appropriate medical staff committee;

(d)

Storage. Emergency kits shall be stored in areas to prevent unauthorized access and to insure a proper environment for preservation of the drugs within them, as required in official compendia;

(e)

Labeling — Interior. All drugs contained in emergency kits shall be labeled in accordance with OAR 855-041-6420 (Emergency Kit and Code Cart);

(f)

Labeling — Exterior. The exterior of emergency kits shall be labeled to clearly and unmistakably indicate that it is an emergency drug kit and it is for use in emergencies only; such label shall also contain a listing of the name, strength and quantity of the drugs contained therein and an expiration date;

(g)

Expiration Date. The expiration date of an emergency kit shall be the earliest expiration date on any drug supplied in the kit. Upon the occurrence of the expiration date, the supplying pharmacist shall open the kit and replace expired drugs;

(h)

Removal of Drugs. Drugs shall be removed from emergency kits by authorized personnel only pursuant to a valid order or by the supplying pharmacist;

(i)

Notifications. Whenever an emergency kit is opened or has expired, the supplying pharmacist shall be notified and the pharmacist shall restock and reseal the kit within a reasonable time so as to prevent risk of harm to patients.

Source: Rule 855-041-6800 — Supervision of Consulting Pharmacist, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=855-041-6800.

855–041–1001
Definitions 855–041–1010
Personnel (Both Retail and Institutional Drug Outlets) 855–041–1015
Operation of Pharmacy (Both Retail and Institutional Drug Outlets) 855–041–1020
Security of Prescription Area 855–041–1025
Disposal of Drugs 855–041–1030
Reporting Drug Loss 855–041–1035
Minimum Equipment Requirements (Both Retail and Institutional Drug Outlets) 855–041–1036
Proper Storage of Drugs 855–041–1040
Drug Outlet Procedures 855–041–1045
Returned Drugs and Devices 855–041–1046
Secure and Responsible Drug Disposal 855–041–1050
Pharmacy Depots 855–041–1055
Confidentiality 855–041–1060
Non-Resident Pharmacies 855–041–1080
Pharmacy Registration (Both Retail and Institutional Drug Outlets) 855–041–1085
Change of Location of a Pharmacy (Both Retail and Institutional Drug Outlets) 855–041–1090
Change of Business Name, Closure (Both Retail and Institutional Drug Outlets) 855–041–1095
Pharmacy Advertising 855–041–1105
Requirements for Prescriptions 855–041–1110
Tamper-resistant Prescription 855–041–1115
Verification of Prescription Authenticity 855–041–1120
Prescription Refills 855–041–1125
Prescription Expiration 855–041–1130
Prescription Labeling 855–041–1131
Prescription Reader Accessibility 855–041–1132
Limited English Proficiency and Accessibility 855–041–1135
Defines Labeling and Container Requirements for Repackage Drugs 855–041–1140
Customized Patient Medication Packages 855–041–1145
New Containers 855–041–1160
Prescription Records and Retention 855–041–1165
Patient Medical Record 855–041–1170
Grounds for Discipline 855–041–2100
Operation of a Double Set-Up Pharmacy in a Retail Drug Outlet 855–041–2115
Transfer of Prescription Information Between Pharmacies 855–041–2310
Definitions 855–041–2320
Epinephrine 855–041–2340
Naloxone 855–041–3000
Central Fill and Remote Processing Outlet Designations and Consulting/Drugless Pharmacy Outlets - Purpose and Scope 855–041–3005
Central Fill - Purpose and Scope 855–041–3010
Central Fill - Definitions 855–041–3015
Central Fill - General Requirements 855–041–3020
Central Fill - Policies and Procedures 855–041–3025
Central Fill - Labeling 855–041–3030
Central Fill - Records 855–041–3035
Central Fill - Delivery of Medications 855–041–3040
Central Fill - Filled Prescriptions 855–041–3045
Central Fill - Prohibited Practices 855–041–3100
Remote Processing - Purpose and Scope 855–041–3105
Remote Processing - Definitions 855–041–3110
Remote Processing - General Requirements 855–041–3115
Remote Processing - Policies and Procedures 855–041–3120
Remote Processing - Records 855–041–3125
Remote Processing - Prescription or Drug Order Processing 855–041–3130
Remote Processing - Prohibited Practices 855–041–3300
Consulting/Drugless Pharmacy - Purpose and Scope 855–041–3305
Consulting/Drugless Pharmacy - Definitions 855–041–3310
Consulting/Drugless Pharmacy - Registration 855–041–3315
Consulting/Drugless Pharmacy - Personnel 855–041–3320
Consulting/Drugless Pharmacy - Confidentiality 855–041–3325
Consulting/Drugless Pharmacy - General Provisions and Minimum Standards 855–041–3330
Consulting/Drugless Pharmacy - Security Requirements 855–041–3335
Consulting/Drugless Pharmacy - Policies and Procedures 855–041–3340
Consulting/Drugless Pharmacy - Records 855–041–4000
Purpose - Expedited Partner Therapy (EPT) 855–041–4005
Expedited Partner Therapy (EPT) - Procedures 855–041–4025
Purpose and Scope - Home Dialysis 855–041–4035
Home Dialysis - Definitions 855–041–4045
Home Dialysis - Drug Delivery and Control 855–041–4055
Home Dialysis - Duties of the Pharmacist 855–041–4100
Definitions - Automated Pharmacy System 855–041–4110
Remote Dispensing Machine (RDM) - Duties and Responsibilities of the Pharmacist-in-Charge 855–041–4120
Remote Dispensing Machine (RDM) - Drug Delivery and Control 855–041–5005
Definitions - Institutional and Residential Pharmacy Drug Outlets 855–041–5015
Registration 855–041–5050
Remote Distribution Facility (RDF) - Definitions 855–041–5055
Remote Distribution Facility (RDF) 855–041–5100
Definitions - Technician Checking Validation Program (TCVP) 855–041–5120
Technician Checking Validation Program (TCVP) - Hospital and Pharmacist in Charge Requirements 855–041–5130
Technician Checking Validation Program (TCVP) - Technician Eligibility and Training 855–041–5140
Technician Checking Validation Program (TCVP) - Initial Validation Process and Quality Assurance Process 855–041–5150
Technician Checking Validation Program (TCVP) - Checking Procedure 855–041–5160
Technician Checking Validation Program (TCVP) - Eligible Specialized Functions 855–041–5170
Technician Checking Validation Program (TCVP) - Records 855–041–6050
Definitions - Automated Distribution Cabinet (ADC) 855–041–6100
Registration 855–041–6150
General Pharmacy Requirements 855–041–6200
Chief Pharmacy Officer and Pharmacist in Charge 855–041–6220
Records 855–041–6240
Drug Administration 855–041–6250
Patient’s Own Drugs and Other Drugs from Outside Sources 855–041–6260
Investigational Drugs 855–041–6270
Labeling 855–041–6300
Absence of the Pharmacist 855–041–6305
Night Cabinet 855–041–6310
After Hours Access to Pharmacy 855–041–6400
Emergency Dispensing by a Nurse 855–041–6410
Emergency Department Distribution 855–041–6420
Emergency Kit and Code Cart 855–041–6500
Practitioner’s Drug Order 855–041–6510
In-patient Drug Profile 855–041–6520
Cart-Fill 855–041–6530
Robotic Distribution Systems 855–041–6540
Automated Distribution Cabinets 855–041–6550
Secondary and Remote Storage 855–041–6560
Floor-Stock 855–041–6570
Trays and Kits 855–041–6600
Controlled Drug Accountability 855–041–6610
Schedule II Drugs 855–041–6620
Electronic Safe Systems 855–041–6800
Supervision of Consulting Pharmacist 855–041–6840
Drug Distribution and Control from a Drug Room in a Hospital 855–041–7050
Definitions - Long Term Care Pharmacy 855–041–7060
Long Term Care Pharmacy - Drug Distribution and Control 855–041–7070
Long Term Care Pharmacy - Labeling and Distribution 855–041–7080
Pharmaceutical Care in Community Based Care Facilities 855–041–8050
Emergency Drug Supply in Home Health Care Agencies
Last Updated

Jun. 8, 2021

Rule 855-041-6800’s source at or​.us