Department of Pharmacy Services

Policies and Procedures


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TABLE OF CONTENTS

ADMINISTRATION

   MISSION AND SCOPE OF SERVICE

   GENERAL ADMINISTRATION 1:00

       1:02  VISION FOR PHARMACY SERVICE

        1:04  PHARMACY STAFFING

        1:05  ORGANIZATIONAL STRUCTURE

        1:06  OPERATING HOURS

        1:07  DEPARTMENTAL SECURITY

        1:08  PHARMACY SAFETY

        1:09  DISASTER PLAN

        1:11  STANDARDS GOVERNING DEPARTMENTAL     OPERATIONS

PERSONNEL  2:00

        2:00  GENERAL PERSONNEL POLICIES

        2:01  JOB DESCRIPTIONS

        2:02  ATTENDANCE

        2:03  STAFF RIGHTS AND RESPONSIBILITIES

        2:04  TIME AND PAYROLL

        2:07  INFECTION CONTROL

        2:08  EMPLOYEE EDUCATION AND TRAINING

        2:09  HOSPITAL PHARMACY RESIDENCY

        2:10  FLOOR PHARMACISTS

        2:11  PHARMACY COMMUNICATIONS

ADMINISTRATION  4:00

        4:00.5  PHARMACY OPERATING PERMITS

        4:01  PRICING SCHEDULES AND AUTHORIZATIONS

        4:02  FEE CODES

        4:03  PRODUCTIVITY REPORTING

        4:04  HOSPITAL FORMULARY

 

        4:05  COMPUTER SECURITY

        4:06  FINANCIAL MANAGEMENT

        4:07  DRUG INFORMATION

        4:08  PHARMACY ADMINISTRATION AND MANAGEMENT

        4:09  OUTSIDE COMPOUNDING AGREEMENT

DRUG DISTRIBUTION - 5:00

        5:00         DRUG DISTRIBUTION

        5:01         DISPENSING SECTION

        5:01.3       PROCESSING AND DISPENSING DRUG ORDERS

        5:01.3.1    PROCESSING AND DISPENSING OF OUT-PATIENT PRESCRIPTIONS

        5:01.4       SURGERY SATELLITE OPERATIONS

                        Click Here for Members of the Anesthesiology Pain Team

        5:01.46     UNIT DOSE DRUG DISTRIBUTION SYSTEM

        5:01.6      STANDARD DRUG ADMINISTRATION SCHEDULE

        5:01.7     MEDICATIONS IN STANDARD PROCEDURE            ORDERS

        5:02        PATIENT MEDICATION PROFILE

        5:03     MEDICATION ORDER REVIEW/RENEWAL

         5:04      SELF-ADMINISTRATION OF MEDICATIONS BY INPATIENTS

        5:05.5    MORNING ADMIT (A.M.) SURGERY

        5:06       ROUTINE, NOW AND STAT ORDERS

        5:07      I.V. ADMIXTURES

        5:08      USE OF AUTOMATED DISPENSING SYSTEM

        5:10      CHEMOTHERAPY ORDERS

        5:12      TOTAL PARENTERAL NUTRITION

        5:12.5      AUTOMATED COMPOUNDING SYSTEM

        5:13         INFUSION PUMPS

        5:14        CONTROLLED DRUGS   

        5:14.5     MANAGEMENT OF THE PHARMACY PYXIS C-II SAFE

        5:14.51   PYXIS C-II SAFE DOWNTIME PROCEDURE

        5:15        DRUG SAMPLES

        5:16        INVESTIGATIONAL DRUGS

        5: 17       MEDICATION BROUGHT TO THE HOSPITAL BY THE PATIENT

        5:18        NON-FORMULARY DRUG ORDERS

        5:19        OUTPATIENT PRESCRIPTIONS DISPENSED BY INPATIENT PHARMACY

        5:20        DISCHARGE PRESCRIPTIONS

        5:21        EMERGENCY ROOM PRESCRIPTIONS

        5:22        EMPLOYEE PRESCRIPTIONS

        5:24        LEAVE OF ABSENCE MEDICATIONS

        5:25        FLOOR STOCK

        5:26        PROCESSING AND DISPENSING MEDICATION TO PATIENTS IN THE OUT  PATIENT  CLINICS

        5:27         EMERGENCY CARTS

        5:30         CHARGE AND REPLACE SYSTEM

        5:31         EMERGENCY DEPARTMENT DRUG SUPPLY

        5:32         MEDICATION STORAGE IN PATIENT CARE AREAS

SUPPLY  6:00 

       6:01        GENERAL SUPPLY

        6:02        PURCHASING PROCEDURES

        6:03        BIDS AND CONTRACTS

        5:28        INTERDEPARTMENTAL ORDERS

        6:04        ORDERING

        6:05        RECEIVING

        6:06        BLOOD DERIVATIVES  

        6:07        CONTROLLED SUBSTANCES

        6:08        RETURNED GOODS

        6:09        LOANING AND BORROWING DRUG ITEMS

        6:10        VENDOR COMPLAINTS

        6:11        DRUG SHORTAGE

        6:12        Distribution of Low Risk Medication/ Solutions

PRODUCTION 7:00

        7:03        PRODUCTION CONTROL  

        7:04        lABELING 

        7:05        CONTROL NUMBER

        7:06        EXPIRATION DATING

        7:07        REPACKAGING

        7:09        FLAMMABLE SOLVENTS AND CHEMICALS

        7:11        TAX FREE ALCOHOL

QUALITY ASSURANCE  8:00

        8:02        INSPECTION OF SUPPLIES UPON RECEIPT

        8:03        INVENTORY INSPECTION FOR EXPIRATION DATING

        8:03.5     EXPIRATION DATING FOR MULTIPLE DOSE VIALS OF INJECTABLES

        8:04        MANUFACTURING CONTROL PROCEDURES

        8:05        CONTROL LABORATORY

        8:06        MEDICATION USE PROCESS IMPROVEMENT   

        8:07        DISPENSING ERROR REPORTING

        8:08        ADVERSE DRUG REACTION REPORTING

        8:09        DRUG PRODUCT RECALLS

        8:10        NURSING STATION INSPECTION

        8:11        HANDLING CYTOTOXIC AGENTS

        8:12        LAMINAR AIR FLOW HOOD

        8:13        STERILE PRODUCTS PREPARATION

        8:14        SECURITY OF CONTROLLED SUBSTANCES

        8:15        MEDICATION ERRORS

        8:16        DRUG-DRUG INTERACTION AND ALLERGY INTERVENTION

        8:17        DOCUMENTATION AND ASSESSMENT OF CLINICAL INTERVENTIONS

CLINICAL PROGRAMS  9:00

        9:01       CONFIDENTIALITY OF PATIENT INFORMATION

        9:02       PHARMACIST WRITING IN THE MEDICAL CHART

        9:03       PRACTICE BY PHARMACISTS NOT EMPLOYED BY        UNIVERSITY HOSPITAL

        9:04       ORDER AMENDMENT OF MEDICATION ORDERS IN E-CHART

        9:06       FOOD AND DRUG INTERACTIONS COUNSELING

        9:07       I.V. PUSH DRUGS

        9:08       INTRAVENOUS TO ORAL DOSING SWITCH

        9:09      PATIENT COUNSELING FOR ESTROGEN DRUG PRODUCTS

        9:10      NON-TRADITIONAL/NON-PRESCRIPTION DRUGS

         9:11     ADMINISTRATION OF HIGH RISK DRUGS

        9:12      HANDLING EPOPROSTENOL

       9:14       PRESCRIBING DRUGS FOR PEDIATRIC PATIENTS

       9:15       MANAGEMENT OF SOUND-ALIKE LOOK ALIKE DRUGS