1. (a)

   1. (1) Any pharmacist practicing in an Arkansas hospital must:

      1. (A) So notify the Arkansas State Board of Pharmacy; and
      2. (B) Ascertain that a hospital pharmaceutical services permit has been issued.
   2. (2) The hospital pharmaceutical services permit shall be issued in the name of the hospital showing a pharmacist-in-charge.
2. (b) Any hospital holding a retail pharmacy permit as of February 15, 1975, upon application for renewal must separate the facilities, stocks, records, etc., in compliance with Arkansas Code §§ 17-92-403 – 17-92-405.

3. (c)

   1. (1) All hospitals shall have adequate provisions for pharmaceutical services regarding the procurement, storage, distribution, and control of all medications.
   2. (2) All federal and state rules shall be complied with.

4. (d) Definitions. As used in this part:

   1. (1) “Hospital employee” means any individual employed by the hospital whose compensation for services or labor actually performed for a hospital is reflected on the payroll records of a hospital;

   2. (2)

      1. (A) “Hospital pharmacy” means the place or places in which drugs, chemicals, medicines, prescriptions, or poisons are prepared for distribution and administration for the use and/or benefit of patients in a hospital licensed by the Department of Health.
      2. (B) “Hospital pharmacy” shall also mean the place or places in which drugs, chemicals, medicines, prescriptions, or poisons are compounded for dispensing to:

5. (i) Hospital employees;

   1. (ii) Members of the immediate families of hospital employees;

      1. (iii) Patients being discharged; and

         1. (iv) Other persons in emergency situations.
      2. (C) “Hospital pharmacy” shall also mean the provision of pharmaceutical services as defined in the Pharmacy Practice Act by a pharmacist to a patient of the hospital;
   2. (3) “Licensed pharmacist” means any person licensed to practice pharmacy by the Arkansas State Board of Pharmacy who provides pharmaceutical services as defined in the Pharmacy Practice Act to patients of the hospital;
   3. (4) “Qualified hospital personnel” means persons other than licensed pharmacists who perform duties in conjunction with the overall hospital pharmaceutical services for inpatients; and

   4. (5)

      1. (A) “Unit dose distribution system” means a pharmacy-coordinated method of dispensing and controlling medications in hospitals in which medications are dispensed in single-unit packages for a specific patient on orders of a physician where not more than a twenty-four-hour supply of said medications is dispensed, delivered, or available to the patient.
      2. (B) “Unit dose distribution system” also means a system that meets the requirement of a “unit dose distribution system”, provided that up to a seventy-two-hour supply may be sent to the floor once a week if the system has been reviewed and approved administratively by the Arkansas State Board of Pharmacy.

6. (e) Compounding, dispensing, and distributing.

   1. (1) Compounding is the act of selecting, mixing, combining, measuring, counting, or otherwise preparing a drug or medication.

   2. (2) Dispensing is a function restricted to licensed pharmacists that involves the issuance of:

      1. (A) One (1) or more doses of a medication in containers other than the original, with such new containers being properly labeled by the dispenser as to content and/or directions for use as directed by the prescriber;
      2. (B) Medication in its original container with a pharmacy-prepared label that carries to the patient the directions of the prescriber as well as other vital information; and

      3. (C)

         1. (i) A package carrying a label prepared for nursing station use.
         2. (ii) The contents of the container may be for one (1) patient (individual prescription) or for several patients (such as a nursing station medication container).

   3. (3)

      1. (A) Distributing, in the context of this part, refers to the movement of a medication from a central point to a nursing station medication center.
      2. (B) The medication must be in the original labeled manufacturer’s container or in a prepackaged container labeled according to federal and state statutes and rules by a pharmacist or under his or her direct and immediate supervision.

7. (f) Administering.

   1. (1) An act, restricted to nursing personnel as defined in the Nurse Practice Act, in which a single dose of a prescribed drug or biological is given a patient.
   2. (2) This activity includes the removal of the dose from a previously dispensed, properly labeled container, verifying it with the prescriber’s orders, giving the individual dose to the proper patient, and recording the time and dose given.

8. (g) Pharmacy and therapeutics committee. There is a committee of the medical staff to confer with the pharmacist in the formulation of policies, explained as follows:

   1. (1)

      1. (A) A pharmacy and therapeutics committee (P&T Committee), composed of at least one (1) physician, the administrator or representative, the director of nursing service or representative, and the pharmacist, is established in the hospital.
      2. (B) It represents the organizational line of communication and the liaison between the medical staff and the pharmacist;
   2. (2) The P&T Committee assists in the formation of broad professional policies regarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in hospitals; and

   3. (3) The P&T Committee performs the following specific functions:

      1. (A) Serves as an advisory group to the hospital medical staff and the pharmacist on matters pertaining to the choice drugs;
      2. (B) Develops and reviews periodically a formulary or drug list for use in the hospital;
      3. (C) Establishes standards concerning the use and control of investigational drugs and research in the use of recognized drugs;
      4. (D) Evaluates clinical data concerning new drugs or preparations requested for use in the hospital;
      5. (E) Makes recommendations concerning drugs to be stocked on the nursing unit floors and emergency drug stocks;
      6. (F) Prevents unnecessary duplication in stocking drugs and drugs in combination having identical amounts of the same therapeutic ingredients;

      7. (G) The P&T Committee:

         1. (i) Meets at least quarterly; and
         2. (ii) Reports to the medical staff by written report; and

      8. (H)

         1. (i) Develops and routinely evaluates a hospital-wide Medication Error Reduction Plan (MERP) to identify actual or potential medication-related errors and to perform a concurrent and retrospective review of clinical care.
         2. (ii) The MERP should address the areas of:
9. (a) (a) Prescribing;

10. (b) (b) Prescription;

    1. (c) (c) Order communication;

       1. (d) (d) Product labeling;
11. (e) (e) Product packaging and nomenclature;
12. (f) (f) Compounding;
13. (g) (g) Dispensing;

14. (h) (h) Distribution;

    1. (i) (i) Administration;
15. (j) (j) Education; and
16. (k) (k) Monitoring and use.

17. (h) Pharmacy operations.

    1. (1) The hospital has a pharmacy directed by a licensed pharmacist.
    2. (2) The pharmacy is administered in accordance with accepted professional principles.

    3. (3) Pharmacy supervision. There is a pharmacy directed by a licensed pharmacist, defined as follows:

       1. (A) The director of pharmacy is trained in the specialized functions of hospital pharmacy;
       2. (B) The director of pharmacy is responsible to the administration of the hospital and the Arkansas State Board of Pharmacy for developing, supervising, and coordinating all the activities of the pharmacy department and all pharmacists providing professional services in the hospital; and

       3. (C)

          1. (i) All licensed pharmacists who provide pharmaceutical services as defined by the Pharmacy Practice Act shall practice under policies, procedures, and protocols approved by the director of pharmacy.
          2. (ii) These policies, procedures, and protocols shall be subject to review and approval by the Arkansas State Board of Pharmacy.
          3. (i) Physical facilities. Facilities are provided for the storage, safeguarding, preparation, and dispensing of drugs, defined as follows:
    4. (1) Drugs are issued to floor units in accordance with approved policies and procedures;

    5. (2)

       1. (A) Drug cabinets on the nursing units are routinely checked by the pharmacist.
       2. (B) All floor stocks are properly controlled;

    6. (3)

       1. (A) A careful determination of the functions of a department will regulate the space to be allocated, the equipment necessary to carry out the functions, and the number of personnel required to utilize the equipment and to render a given volume of service, as these functions relate to the frequency or intensity of each function or activity.
       2. (B) Adequate equipment should specifically relate to services rendered and functions performed by the hospital pharmacy.

       3. (C) Equipment lists will relate to the following services and functions:

          1. (i) Medication preparation;
          2. (ii) Library reference facilities;
          3. (iii) Record and office procedures;
          4. (iv) Sterile product manufacturing;
          5. (v) Bulk compounding (manufacturing);
          6. (vi) Product control (assay, sterility testing, etc.); and
          7. (vii) Product development and special formulations for medical staff;

    7. (4) Equipment appropriate for the hospital pharmacy’s specific scope of practice shall be maintained by the pharmacy and may include but is not limited to:

       1. (A) Graduates capable of measuring from one-tenth of a milliliter (0.1 ml) up to at least five hundred milliliters (500 ml);
       2. (B) Mortars and pestles;
       3. (C) Hot and cold running water;
       4. (D) Spatulas, steel and nonmetallic;
       5. (E) Funnels;
       6. (F) Stirring rods;
       7. (G) Class A balance and appropriate weights;
       8. (H) Typewriter or other label printer;
       9. (I) Suitable apparatus for production of small-volume sterile products; and
       10. (J) Suitable containers and labels;

    8. (5) Each hospital pharmacy shall maintain a pharmacy library available for use by the pharmacist and the patient, including:

       1. (A) Either current drug information manuals or computers capable of printing current drug information for the pharmacist and patient drug information and monographs for patients; and
       2. (B) Other pharmacy reference books and periodicals necessary for effective pharmacy practice; and

    9. (6) Special locked storage space is provided to meet the legal requirements for storage of:

       1. (A) Controlled drugs;
       2. (B) Alcohol; and
       3. (C) Other prescribed drugs;

18. (j) Personnel. Personnel competent in their respective duties are provided in keeping with size and activity of the department, explained as follows:

    1. (1) The director of pharmacy is assisted by an adequate number of additional licensed pharmacists and such other personnel as the activities of the pharmacy may require to ensure quality pharmaceutical services; and

    2. (2) The pharmacy, depending upon the size and scope of its operations, is staffed by the following categories of personnel:

       1. (A) Chief pharmacist (director of pharmacy);
       2. (B) One (1) or more assistant chief pharmacists (assistant director of pharmacy);
       3. (C) Staff pharmacists;
       4. (D) Pharmacy residents, where program has been activated;
       5. (E) Trained nonprofessional pharmacy helpers (qualified hospital personnel); and
       6. (F) Clerical help.

19. (k) Emergency pharmaceutical services. Through the administrator of the hospital, the P&T Committee shall establish policies and procedures that include but are not limited to the following:

    1. (1) Upon admission to the emergency room on an outpatient basis and when examined by the physician where medications are prescribed to be administered, a record must be kept on file in the emergency room admission book or a copy of the emergency room medication order must be kept by the pharmacist to be readily accessible, for control and other purposes, as required by this part;

    2. (2)

       1. (A) If the physician wishes the patient to have medication to be taken with them from the emergency room supplies, the amounts to be taken shall be sufficient to last until medication may be obtained from local pharmacies, in any case not to exceed a forty-eight-hour supply.
       2. (B) All state and federal laws must be observed concerning all records, labeling, and outpatient dispensing requirements; and

    3. (3) Take-home prescriptions for anti-infectives issued to patients at the time of discharge from the emergency room, filled by a pharmacist, shall be quantities consistent with the medical needs of the patient.

       1. (l) Pharmacy records and labeling.

    4. (1) Records are:

       1. (A) Kept of the transactions of the pharmacy; and
       2. (B) Correlated with other hospital records where indicated.
    5. (2) All medication shall be properly labeled.

    6. (3) Such record and labeling requirements are as follows:

       1. (A) The pharmacy establishes and maintains, in cooperation with the accounting department, a satisfactory system of records and bookkeeping in accordance with the policies of the hospital for:

          1. (i) Maintaining adequate control over the requisitioning and dispensing of all drugs and pharmaceutical supplies; and
          2. (ii) Charging patients for drugs and pharmaceutical supplies;
       2. (B) A record of procurement and disbursement of all controlled drugs is maintained in such a manner that the disposition of any particular item may be readily traced;
       3. (C) The pharmacist shall receive and provide service pursuant to the perusal of the physician’s original order or a direct copy thereof, except in emergency situations wherein the pharmacist may provide service pursuant to a verbal order or to an oral or written transcription of the physician’s order provided that the pharmacist shall receive and review the original or direct copy within twenty-four (24) hours of the time the service is provided;

       4. (D) A record shall be maintained by the pharmacy and stored separately from other hospital records for each patient, inpatient or outpatient, containing the:

          1. (i) Name of the patient;
          2. (ii) Prescribing physician;
          3. (iii) Name and strength of drugs prescribed; and
          4. (iv) Name and manufacturer or trademark of medication dispensed;

       5. (E)

          1. (i) The label of each medication container prepared for administration to inpatients shall bear the:
20. (a) (a) Name and strength of the medication;

21. (b) (b) Expiration date; and

    1. (c) (c) Lot and control number.

       1. (ii) The label on the medication, or the container into which the labeled medication is placed, must bear the name of the patient; and

       2. (F) The label of each outpatient’s individual prescription medication container bears the name of the patient, prescribing physician, directions for use, and the name and strength of the medication dispensed, unless directed otherwise by the physician.

          1. (m) Control of toxic or dangerous drugs. Policies are established to control the administration of toxic or dangerous drugs with specific reference to the duration of the order and the dosage, explained as follows:
    2. (1) The medical staff has established a written policy that all toxic or dangerous medications not specifically prescribed as to time or number of doses will be automatically stopped after a reasonable time limit set by the staff;

    3. (2) The classifications ordinarily thought of as toxic or dangerous drugs are:

       1. (A) Controlled substances;
       2. (B) Anticoagulants;
       3. (C) Antibiotics;
       4. (D) Oxytoxics; and
       5. (E) Cortisone products;
    4. (3) Except for controlled drugs, all deteriorated nonsterile, nonlabeled, or damaged medication shall be destroyed by the pharmacist; and
    5. (4) All controlled drugs (Schedules II, III, IV, and V) should be listed and a copy sent along with the drugs to the Department of Health by registered mail or delivered in person for disposition.

22. (n) Drugs to be dispensed. Therapeutic ingredients of medications dispensed are included, or approved for inclusion, in the USP-NF and Homeopathic Pharmacopoeia of the United States, or Accepted Dental Remedies, except for any drugs unfavorably evaluated therein, and drugs approved by provisions of Acts 1975, No. 436, or are approved for use by the P&T Committee of the hospital staff, explained as follows:

    1. (1) The pharmacist, with the advice and guidance of the P&T Committee, is responsible for specifications as to quality, quantity, and source of supply of all drugs; and
    2. (2) There is available a formulary or list of drugs accepted for use in the hospital that is developed and amended at regular intervals by the P&T Committee with the cooperation of the pharmacist and the administration.

23. (o) Policy and procedure manual.

    1. (1) A policy and procedure manual pertaining to the operations of the hospital pharmacy with updated revisions adopted by the P&T Committee of each hospital shall be prepared and maintained at the hospital.

    2. (2) The policy and procedure manual should include at a minimum the following:

       1. (A) Provisions for procurement, storage, distribution, and drug control for all aspects of pharmaceutical services in the hospital;
       2. (B) Specialized areas such as surgery, delivery, ICU and CCU units, and emergency room stock and usage of medication shall be specifically outlined;
       3. (C) A system of requisitioning supplies and medications for nurses’ stations stock shall be in written procedural form as to limits of medications to be stocked in each nursing unit;
       4. (D) Detailed job descriptions and duties of each employee by job title working in the pharmacy department must be developed and made a part of these policies and procedures; and
       5. (E) The pharmacy policy and procedure manual shall be subject to review and approval by the Arkansas State Board of Pharmacy on request from the Arkansas State Board of Pharmacy.

24. (p) Employee prescription medication.

    1. (1)

       1. (A) There will be a prescription on file for all prescription drugs dispensed to hospital employees and their immediate families.
       2. (B) These records will be kept separate from all inpatient records.
    2. (2) The only person or persons entitled to have employee prescriptions filled will be the employee listed on the hospital payroll and members of his or her immediate family.
25. (q) Patient discharge medication. Any take-home prescription dispensed to patients at time of discharge from the hospital shall be for drugs and quantities consistent with the immediate medical needs of the patient.

26. (r) Licensed pharmacist personnel requirements. The minimum requirements for licensed pharmacists in hospitals are:

    1. (1)

       1. (A) A general hospital, surgery, and general medical care maternal and general medical care hospital, chronic disease hospitals, psychiatric hospitals, and rehabilitative facilities licensed for greater than fifty (50) beds, as determined by the institution’s license issued by the Department of Health, shall require the services of a pharmacist-in-charge, who shall be responsible for duties defined in 17 CAR § 160-1010.
       2. (B) Additional pharmacists shall be employed as are necessary to perform required pharmacy duties in keeping with the size and scope of the services of the hospital pharmacy’s safe and efficient operation in the opinion of the Arkansas State Board of Pharmacy.
       3. (C) Hospitals providing specialized or unique patient care services may request approval from the Arkansas State Board of Pharmacy to be exempt from the requirement of a pharmacist on duty forty (40) hours per week.
       4. (D) The request for exemption must provide adequate written documentation to justify the services of a pharmacist for as many hours as are necessary to perform required pharmacy services, followed by an appearance before the Arkansas State Board of Pharmacy for final approval of the request;

    2. (2)

       1. (A) The above classified hospitals, licensed for fifty (50) beds or fewer, as determined by the institution’s license issued by the Department of Health, shall require the services of a pharmacist or pharmacists including a pharmacist-in-charge, for as many hours as, in the opinion of the Arkansas State Board of Pharmacy and the State Board of Health, are necessary to perform required pharmacy duties in keeping with the size and scope of the services of the hospital pharmacy’s safe and efficient operation.
       2. (B) The pharmacist or pharmacists shall be on site at least five (5) days per week to perform and review pharmacy dispensing, drug utilization, and drug distribution activities.
       3. (C) A pharmacist shall be available to provide emergency services to the staff when the pharmacy is closed;

    3. (3) Recuperative centers, outpatient surgery centers, and infirmaries.

       1. (A) If the infirmary, recuperative center, or outpatient surgery center has a pharmacy department, a licensed pharmacist must be employed to administer the pharmacy in accordance with all state and federal laws regarding drugs and drug control.
       2. (B) If the infirmary, recuperative center, or outpatient surgery center does not have a pharmacy department, it has provisions for promptly and conveniently obtaining prescribed drugs and biologicals from a community or institutional pharmacy.

       3. (C)

          1. (i) If the infirmary, recuperative center, or outpatient surgery center does not have a pharmacy department but does maintain a supply of drugs, a licensed pharmacist shall:
27. (a) (a) Be responsible for the control of all bulk drugs; and

28. (b) (b) Maintain records of their receipt and disposition.

    1. (ii) The pharmacist shall dispense drugs from the drug supply, properly labeled, and make them available to appropriate nursing personnel.

       1. (D) All medication for patients shall be on individual prescription basis; and
    2. (4) A pharmacist-in-charge, who is employed at any facility permitted by the Arkansas State Board of Pharmacy where a forty-hour work week is required, may also be the pharmacist-in-charge at a hospital licensed for fifty (50) beds or fewer by the Department of Health.

29. (s) Responsibility of a pharmacist in a hospital pharmacy.

    1. (1) The pharmacist-in-charge is responsible for the:

       1. (A) Control of all medications distributed in the hospital where he or she practices; and
       2. (B) Proper provision of all pharmaceutical services.

    2. (2) The following aspects of medication distribution and pharmaceutical service are functions involving professional evaluations of judgments and may not be performed by supportive personnel:

       1. (A) Selection of the brand and supplier of medication;

       2. (B)

          1. (i) Interpretation and certification of the medication order.
          2. (ii) This involves a number of professional responsibilities such as the determination of:
30. (a) (a) Accuracy and appropriateness of dose and dosage schedule;

31. (b) (b) Such items as possible drug interactions, medication sensitivities of the patient, and chemical and therapeutic incompatibilities; and

    1. (c) (c) Accuracy of entry of medication order to patient’s medication profile; and
    2. (3) Final certification of the prepared medication.

32. (t) Operation of pharmacy department without a pharmacist. At no time will the hospital pharmacy be open and in operation unless a licensed pharmacist is physically present except:

    1. (1) Entrance may be obtained for emergency medication as set forth in the pharmacy policy and procedure manual when the pharmacy is closed outside its normal operation hours; or
    2. (2) When the pharmacist is summoned away from the pharmacy and there are other qualified personnel left in the pharmacy, the personnel left in the pharmacy could perform only those functions authorized within this part.
33. (u) The American Society of Health-System Pharmacists Guidelines. The American Society of Health-System Pharmacists’ most recent statement on hospital drug control systems and Guidelines for Institutional Use of Controlled Substances shall be required reading by hospital pharmacists.

Codification Notes: This section as promulgated prior to codification into the Code of Arkansas Rules provided as follows: “(Revised 6/25/83, 4/7/89, 6/15/95, 8/2001, 11/1/2007, 11/6/2008 and 11/30/2010)" "USP-NF" means United States Pharmacopeia-National Formulary. "ICU" means intensive care unit. "CCU" means critical care unit.