WAC 246-324-210: Pharmacy and medication services

Link to law: http://apps.leg.wa.gov/wac/default.aspx?cite=246-324-210
Published: 2015

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WACs > Title 246 > Chapter 246-324 > Section 246-324-210











246-324-200    

246-324-220







No agency filings affecting this section since 2003







WAC 246-324-210









Pharmacy and medication services.









The licensee shall:
(1) Maintain the pharmacy in the hospital in a safe, clean, and sanitary condition;
(2) Provide evidence of current approval of pharmacy services by the Washington state board of pharmacy under chapter 18.64 RCW;
(3) Develop and implement procedures for prescribing, storing, and administering medications according to state and federal laws and rules, including:
(a) Assuring professional staff who prescribe are authorized to prescribe under chapter 69.41 RCW;
(b) Assuring orders and prescriptions for medications administered and self-administered include:
(i) Date and time;
(ii) Type and amount of drug;
(iii) Route of administration;
(iv) Frequency of administration; and
(v) Authentication by professional staff;
(c) Administering drugs;
(d) Self-administering drugs;
(e) Receiving and recording or transcribing verbal or telephone drug orders by authorized staff;
(f) Authenticating verbal and telephone orders by prescriber in a timely manner, not to exceed forty-eight hours for inpatients;
(g) Use of medications and drugs owned by the patient but not dispensed by the hospital pharmacy, including:
(i) Specific written orders;
(ii) Identification and administration of drug;
(iii) Handling, storage and control;
(iv) Disposition; and
(v) Pharmacist and physician inspection and approval prior to patient use to ensure proper identification, lack of deterioration, and consistency with current medication profile;
(h) Maintaining drugs in patient care areas of the hospital including:
(i) Hospital pharmacist or consulting pharmacist responsibility;
(ii) Legible labeling with generic and/or trade name and strength as required by federal and state laws;
(iii) Access only by staff authorized access under hospital policy;
(iv) Storage under appropriate conditions specified by the hospital pharmacist or consulting pharmacist, including provisions for:
(A) Storing medicines, poisons, and other drugs in a specifically designated, well-illuminated, secure space;
(B) Separating internal and external stock drugs; and
(C) Storing Schedule II drugs in a separate locked drawer, compartment, cabinet, or safe; and
(i) Preparing drugs in designated rooms with ample light, ventilation, sink or lavatory, and sufficient work area;
(j) Prohibiting the administration of outdated or deteriorated drugs, as indicated by label;
(k) Restricting access to pharmacy stock of drugs to:
(i) Legally authorized pharmacy staff; and
(ii) Except for Schedule II drugs, to a registered nurse designated by the hospital when all of the following conditions are met:
(A) The pharmacist is absent from the hospital;
(B) Drugs are needed in an emergency, and are not available in floor supplies; and
(C) The registered nurse, not the pharmacist, is accountable for the registered nurse's actions;
(4) The appropriate professional staff committee shall approve all policies and procedures on drugs, after documented consultation with:
(a) The pharmacist or pharmacist consultant directing hospital pharmacy services; and
(b) An advisory group comprised of representatives from the professional staff, hospital administration, and nursing services;
(5) When planning new construction of a pharmacy:
(a) Follow the general design requirements for architectural components, electrical service, lighting, call systems, hardware, interior finishes, heating, plumbing, sewerage, ventilation/air conditioning, and signage in WAC 246-318-540;
(b) Provide housekeeping facilities within or easily accessible to the pharmacy;
(c) Locate pharmacy in a clean, separate, secure room with:
(i) Storage, including locked storage for Schedule II controlled substances;
(ii) All entrances equipped with closers;
(iii) Automatic locking mechanisms on all entrance doors to preclude entrance without a key or combination;
(iv) Perimeter walls of the pharmacy and vault, if used, constructed full height from floor to ceiling;
(v) Security devices or alarm systems for perimeter windows and relites;
(vi) An emergency signal device to signal at a location where twenty-four-hour assistance is available;
(vii) Space for files and clerical functions;
(viii) Break-out area separate from clean areas; and
(ix) Electrical service including emergency power to critical pharmacy areas and equipment;
(d) Provide a general compounding and dispensing unit, room, or area with:
(i) A work counter with impermeable surface;
(ii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;
(iii) Storage space;
(iv) A refrigeration and freezing unit; and
(v) Space for mobile equipment;
(e) If planning a manufacturing and unit dose packaging area or room, provide with:
(i) Work counter with impermeable surface;
(ii) Corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter; and
(iii) Storage space;
(f) Locate admixture, radiopharmaceuticals, and other sterile compounding room, if planned, in a low traffic, clean area with:
(i) A preparation area;
(ii) A work counter with impermeable surface;
(iii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;
(iv) Space for mobile equipment;
(v) Storage space;
(vi) A laminar flow hood in admixture area; and
(vii) Shielding and appropriate ventilation according to WAC 246-318-540 (3)(m) for storage and preparation of radiopharmaceuticals;
(g) If a satellite pharmacy is planned, comply with the provisions of:
(i) Subsection (5)(a), (5)(c)(i), (ii), (iii), (iv), (v), and (vi) of this section when drugs will be stored;
(ii) Subsection (5)(c)(vii), (viii), and (ix) of this section, if appropriate; and
(iii) Subsections (5)(d) and (g) of this section if planned;
(h) If a separate outpatient pharmacy is planned, comply with the requirements for a satellite pharmacy including:
(i) Easy access;
(ii) A conveniently located toilet meeting accessibility requirements in WAC 51-20-3100; and
(iii) A private counseling area.
[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-013, § 246-324-210, filed 10/20/95, effective 11/20/95.]