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A log of drugs withdrawn from a drug room shall be maintained and initialed by the registered nurse;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