1. 1. Pharmaceutical services are provided under the direction of a pharmacist according to A.R.S. Title 36, Chapter 27; A.R.S. Title 32, Chapter 18; and 4 A.A.C. 23;
2. 2. A copy of the pharmacy license is provided to the Department for review upon the Department’s request;

3. 3. A committee, composed of at least one physician, one pharmacist, and other personnel members as determined by policies and procedures, is established to:

   1. a. Develop a drug formulary,
   2. b. Update the drug formulary at least once every 12 months,
   3. c. Develop medication usage and medication substitution policies and procedures, and
   4. d. Specify which medications and medication classifications are required to be automatically stopped after a specified time period unless the ordering medical staff member specifically orders otherwise;
4. 4. An expired, mislabeled, or unusable medication is disposed of according to policies and procedures;
5. 5. A medication administration error or an adverse reaction is reported to the ordering medical staff member or the medical staff member’s designee;
6. 6. A pharmacy medication dispensing error is reported to the pharmacist;
7. 7. In a pharmacist’s absence, personnel members designated by policies and procedures have access to a locked area containing a medication;
8. 8. A medication is maintained at temperatures recommended by the manufacturer;

9. 9. A cart used for an emergency:

   1. a. Contains medication, supplies, and equipment as specified in policies and procedures;
   2. b. Is available to a unit; and
   3. c. Is sealed until opened in an emergency;
10. 10. Emergency cart contents and sealing of the emergency cart are verified and documented according to policies and procedures;

11. 11. Policies and procedures specify individuals who may:

    1. a. Order medication, and
    2. b. Administer medication;
12. 12. A medication is administered in compliance with an order;
13. 13. A medication administered to a patient is documented as required in R9-10-213;

14. 14. If pain medication is administered to a patient, documentation in the patient’s medical record includes:

    1. a. An assessment of the patient’s pain before administering the medication, and
    2. b. The effect of the pain medication administered; and

15. 15. Policies and procedures specify a process for review through the quality management program of:

    1. a. A medication administration error,
    2. b. An adverse reaction to a medication, and
    3. c. A pharmacy medication dispensing error.
16. 16. If applicable, policies and procedures are established for donated medicine according to A.R.S. § 32-1909.

An administrator shall ensure that:

Historical Note

Adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Section R9-10-218 renumbered to R9-10-219; new Section R9-10-218 renumbered from R9-10-217 and amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2). Amended by final rulemaking at 31 A.A.R. 2457 (July 25, 2025), effective August 30, 2025 (Supp. 25-3).