A. All medical orders (medications and treatments) shall be in writing and signed by the prescriber. Telephone/verbal orders should be used infrequently. When used they shall be given only to licensed nurses and signed by the prescriber.

B. No medication shall be dispensed or administered without a written order signed by a licensed prescriber. A pharmacist may receive telephone or verbal orders for medications from a prescriber and record them on the medical record.

C. Medications shall be administered by licensed nursing personnel in accordance with the current Arkansas Nurse Practice Act. Other personnel may administer medications only in accordance with their current Practice Act (e.g., Respiratory, Physical Therapy).

D. Blood transfusions and intravenous medications administered by licensed nursing personnel shall be in accordance with State law. If not administered by a Registered Nurse, only licensed nursing personnel who have documentation of training shall be permitted to administer blood transfusions and intravenous medications.

E. There shall be an effective hospital procedure for reporting transfusion reactions and adverse medication reactions.

F. All medications shall be properly labeled and stored in a specifically designated medication cabinet, cart or room. At nursing stations, medications shall only be accessible to licensed nursing personnel and pharmacists. In specialty units and treatment areas, medications shall only be accessible to licensed nursing personnel, pharmacists, and designated licensed personnel consistent with that unit (e.g., Respiratory, Physical Therapy).

G. Refrigeration shall be provided for the proper storage of biologicals and other medications. Medications shall be stored in a separate compartment or area from food. Employee foods and/or medications shall be stored in a separate refrigeration area. An internal thermometer shall be provided and checked daily (or at least weekly when the unit is closed) with documentation to assure temperatures between 36°-46° Fahrenheit (two to eight degrees Centigrade). Refrigerated controlled substances shall meet the requirement for double-lock security.

H. Unused or damaged medications shall be returned to the pharmacy. All medications with incorrect or soiled labels shall be returned to the pharmacy for relabeling.

I. In addition to patients' medical records, a record of the procurement and disposition of each controlled substance shall be maintained at each nursing and specialty unit. Each entry on the disposition record shall reflect the actual dosage administered to the patient, the patient's name, the date, time, and signature of the licensed person administering the medication. (Licensed personnel who may legally administer controlled substances shall include only those personnel authorized by their current Practice Act. Any error of entry on the disposition record shall follow a policy for correction of errors and accurate accountability. If the licensed person who procures the medication from the double-lock security is not the licensed person who administers the medication, then both persons shall sign the disposition record.

J. When breakage or wastage of a controlled substance occurs, the amount given and the amount wasted shall be recorded by the licensed person who wasted the medication and verified by the signature of a licensed person who witnessed the wastage. Documentation shall include or policy shall delineate how the medication was wasted. In addition to the above referenced licensed personnel (see I), licensed Pharmacists shall be allowed to witness wastage of controlled substances. When a licensed person is not available to witness wastage, the partial dose shall be sent to the Arkansas Department of Health, Pharmacy Services and Drug Control for destruction.

K. There shall be an audit each shift change of all controlled substances stocked on the unit. At nursing stations such counts shall be recorded by the oncoming nurse and witnessed by the off-going nurse. At other units, audits shall be performed by two licensed personnel. In each case, both licensed personnel shall sign the record with notation made as to date and time of the audit. If discrepancies are noted, the Director of Nursing, the Department Director, as applicable, and the Director of Pharmacy shall be notified. As with the witnessing of wastage, licensed Pharmacists shall be allowed to witness controlled substance audits.

L. If specialty units are not staffed on every shift, controlled substances shall be audited by two licensed personnel on each shift that is covered by licensed personnel.

M. Controlled substances in areas that are covered only by on-call personnel shall be audited each shift the area is used and at least weekly; whichever time frame is less.

N. Solutions and medications for “external use only” shall be kept separate from other medications.

O. When a patient is discharged, the unused portion of the patient's medication may be sent home with the patient on direct written order of the attending physician; and only after the medication has been relabeled by the pharmacy. Documentation shall include the amount dispensed to the patient and quantities shall be consistent with the immediate needs of the patient.

P. Policies and procedures shall be developed and implemented for the handling of medications brought into the facility by the patient.

Q. All medication errors and adverse drug reactions shall be reported to the attending physician. A copy of all medications errors and adverse drug reactions shall be sent to the Director of Nursing or designee, QA/PI Committee and when appropriate, to the Director of Pharmacy.

R. Records generated by Automatic Medication Distribution Devices shall comply with these rules. Policies and Procedures for the usage of Automatic Medication Distribution Devices shall be approved administratively by Health Facility Services prior to their usage.

S. Drug Security.