Pharmacy service has the ultimate responsiblity for the purchase and distribution of all products which bear a Federal Legend requiring a prescription for use.  With approval of the P&T committee, certain  bulk intravenous solutions,  irrigation solutions, and procedure kits which may contain a legend product may be ordered by hospital personnel in Materials management/Central Sterile Supply (MM/CSS).  These personnel may also perform the related inventory and stocking functions for these products.  

A.    All Legend items, medications/solutions or kits stored and processed through MM/CSS are defined and approved by the P&T Committee. ( See attached list.)  Any new item must be presented to the P&T committee for approval to allow stocking.

B.    All products shall meet the standards of the recognized drug standards compendia and shall be purchased from reputable companies that meet good manufacturing practices. 

C.    Storage of these legend products will allow for identification of expired, mislabeled or deteriorated drugs.  Storage will be maintained at a normal room temperature.  No refrigerated items will be distributed through MM/CSS.  No controlled substances will be distributed through MM/CSS.

D.    The Director of Pharmacy Service or designee shall make monthly inspections of the storage area  to check for dating, security, product appearance, and cleanliness of the storage.

E.    All items stocked in the Omni-Cells will be monitored monthly for expiration dating by MM/CSS.

F.    All product recalls will be documented and handled in a collaborative manner between the pharmacy and MM/CSS.