Drug Distribution Policy and Procedures - Rehabilitative Mental Health Services
I. ORDERS FOR
MEDICATION
A. No drugs shall be administered except
on the written order of a physician lawfully authorized to give such an
order.
B. Telephone orders by a physician for
medication administration shall be given only to a physician,
pharmacist, licensed nurse, or psychiatric technician. The physician
giving the verbal order must, within 5 days, sign these orders.
C. All orders for drug administration
shall be entered into the patient’s medical record/chart and signed by
the prescriber. Medication orders must include:
-
drug name
-
dosage strength
-
quantity or duration of therapy
-
frequency or time of administration
-
route of administration
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II. ADMINISTRATION OF
DRUGS
Definition: Providing a patient with
medication for immediate use, through either the oral or intramuscular
route.
A. Drugs will be administered as
prescribed. Each dose shall be recorded in the patient medical record
with date, dose, time administered, signature and site of IM injection.
B. All intramuscular (IM) medications
administered must be documented on the IM Medication Administration
Record, located in the Medical Section of the Patient’s Chart (see
Physician Order Sheet
for IM Medications)
C. Only a physician, nurse, or
psychiatric technician will administer drugs.
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III. DISPENSING OF DRUGS
Definition: Providing a patient with a
supply of medication for home use.
A. Drugs will be dispensed by a physician
or pharmacist, only in an urgent situation, in full compliance of
applicable laws and regulations.
B. A record of the drug dispensed will be
entered on the patient’s medical record/profile.
C. The label of all dispensed medication
must include:
1. manufacturer’s trade name or generic
name and manufacturer’s name
2. directions for use of the drug
3. name of the patient
4. name of the prescriber
5. date of issue
6. name and address of the furnisher
7. prescription number or other means of
identifying the prescription
8. strength of drug prescribed
9. quantity of drug supplied
10. medication expiration date
D. An Urgent Supply of medication may be
available at the clinic.
1. This Urgent Supply may include:
|
DRUG NAME |
DOSE |
FORM |
|
benztropine
|
2 mg/2 ml |
inj |
|
diphenhydramine
|
50 mg/1 ml |
inj |
|
Epinephine
|
1 mg |
inj |
|
Fluphenazine
decanoate* |
25 mg/ml |
inj |
|
Haloperidol
decanoate* |
100 mg/ml |
inj |
*Only Crisis Response Services
2. The Clinic Director, a nurse or a
physician will be responsible for this Urgent Supply, its storage in a
secure area, monthly checking of expiration dates, and restocking the
supply. The above person responsible for these functions will be
identified in writing to BHCS prior to receiving any medications.
E. No physician samples will be stocked
or dispensed in any Alameda County Behavioral Health Care Services
program.
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IV. LABELING AND STORAGE
OF DRUGS
A. All drugs will be kept in a secure,
locked cabinet or drawer.
B. The Urgent Supply of Medication will
be kept in a secure, locked cabinet or drawer.
C. Drugs will be stored in an orderly
manner, organized by generic name.
D. Drugs will be stored in a secure area
accessible only to the physicians, nurses, pharmacists and the
designated Clinic Director.
E. Drugs will not be retained after the
expiration date indicated on the label. No contaminated or deteriorated
drugs are to be available for use.
F. No single dose IM injectable will be
stored.
G.
All multiple dose IM injectable
medications will be initialed and have the date of first entry recorded
on the label.
H. Each medication expiration date will
be checked on a monthly basis and documented by the Clinic Director (see
attachment #2) or designated person. The above person responsible for
these functions will be identified in writing to BHCS prior to receiving
any medications.
I. Containers, which are cracked,
soiled, or without secure closure shall not be used.
J. Drugs intended for external use will
be stored separately from oral or injectable medications.
K. Test reagents, germicides,
disinfectants, and other non-ingestible substances shall be stored
separately from drugs.
L. All drugs will be stored at
appropriate temperatures:
1. Drugs requiring room temperature
shall be stored in a place maintained between 15-30 degrees C (59-86
degrees F).
2. Drugs requiring refrigeration
shall be stored in a refrigerator maintained between 2-8 degrees C
(36-46 degrees F).
3. Drugs stored in a refrigerator
used also for food storage shall be confined to a closed contained
clearly labeled “DRUGS”.
M. All drugs obtained by prescription
will be labeled in compliance with federal and state laws.
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V. DISPOSAL OF
DRUGS
Drugs, which are expired or removed from
stock due to contamination, deterioration, or medication that has been
abandoned by individuals, will be documented by the clinic (see
Medication
Disposal/Return Sheet). Then the BHCS Clinical Pharmacist Specialist
(567-8110 or x38110) will be notified to provide further instructions
regarding disposal or returning medication to the manufacturer.
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When medications are
dispensed at one of the BHCS programs, but not part of the routine
services, the following procedures shall be followed regarding
procurements, storage, and dispensing by the physician or nurse at the
site:
Procurement
Any request for
medication must be through the BHCS Director of Pharmacy Services
(567-8110). If appropriate, the medication will be delivered to the
physician or nurse at the program.
Storage
The medication will
be secured with the other Urgent Meds at the program. This means locked
in a cabinet, within a locked room. In addition, access to these
medications is limited to physicians, nurses and pharmacy personnel.
Medications will be monitored monthly for expiration by the program
physician or nurse, and that review will be documented on
Monthly
Medication Expiration Date Inspection. If any medication has expired,
the disposal of that medication will be documented on Medication
Disposal/Return Sheet.
Dispensing
When medications are
occasionally dispensed to patients at that program, the following
information must be documented on
Medication Dispensing Log.
- Date
- Patient Name
- PSP#
- Allergy Assessment
- Medication dispensed
- Initials of physician or nurse
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