1. A. An administrator shall ensure that policies and procedures for medication services:

   1. 1. Include:

      1. a. A process for providing information to a patient about medication prescribed for the patient including:

         1. i. The prescribed medication’s anticipated results,
         2. ii. The prescribed medication’s potential adverse reactions,
         3. iii. The prescribed medication’s potential side effects, and
         4. iv. Potential adverse reactions that could result from not taking the medication as prescribed;

      2. b. Procedures for preventing, responding to, and reporting:

         1. i. A medication error,
         2. ii. An adverse reaction to a medication, or
         3. iii. A medication overdose; and
      3. c. Procedures to ensure that a patient’s medication regimen is reviewed by a medical practitioner to ensure the medication regimen meets the patient’s needs; and

   2. 2. Specify a process for review through the quality management program of:

      1. a. A medication administration error, and
      2. b. An adverse reaction to a medication.

2. B. An administrator shall ensure that:

   1. 1. Policies and procedures for medication administration:

      1. a. Are reviewed and approved by a medical practitioner;

      2. b. Specify the individuals who may:

         1. i. Order medication, and
         2. ii. Administer medication;
      3. c. Ensure that medication is administered to a patient only as prescribed; and
      4. d. Cover the documentation of a patient’s refusal to take prescribed medication in the patient’s medical record;
   2. 2. Verbal orders for medication services are taken by a nurse, unless otherwise provided by law; and

   3. 3. A medication administered to a patient:

      1. a. Is administered in compliance with an order, and
      2. b. Is documented in the patient’s medical record.

3. C. An administrator shall ensure that:

   1. 1. A current drug reference guide is available for use by personnel members;
   2. 2. A current toxicology reference guide is available for use by personnel members; and

   3. 3. If pharmaceutical services are provided on the premises:

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

         1. i. Develop a drug formulary,
         2. ii. Update the drug formulary at least once every 12 months,
         3. iii. Develop medication usage and medication substitution policies and procedures, and
         4. iv. Specify which medications and medication classifications are required to be stopped automatically after a specific time period unless the ordering medical staff member specifically orders otherwise;
      2. b. The pharmaceutical services are provided under the direction of a pharmacist;
      3. c. The pharmaceutical services comply with A.R.S. Title 36, Chapter 27; A.R.S. Title 32, Chapter 18; and 4 A.A.C. 23; and
      4. d. A copy of the pharmacy license is provided to the Department upon request.

4. D. When medication is stored at an outpatient surgical center, an administrator shall ensure that:

   1. 1. Medication is stored in a separate locked room, closet, or self-contained unit used only for medication storage;
   2. 2. Medication is stored according to the instructions on the medication container; and

   3. 3. Policies and procedures are established, documented, and implemented for:

      1. a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication, including expired medication;
      2. b. Discarding or returning prepackaged and sample medication to the manufacturer if the manufacturer requests the discard or return of the medication;
      3. c. A medication recall and notification of patients who received recalled medication;
      4. d. Storing, inventorying, and dispensing controlled substances; and
      5. e. If applicable, donated medicine according to A.R.S. § 32-1909.
5. E. An administrator shall ensure that a personnel member immediately reports a medication error or a patient’s adverse reaction to a medication to the medical practitioner who ordered the medication and, if applicable, the outpatient surgical center’s director of nursing.

Historical Note

Adopted effective October 20, 1982 (Supp. 82-5). Section repealed, new Section adopted effective February 17, 1995 (Supp. 95-1). Section repealed; new Section made by final rulemaking at 9 A.A.R. 338, effective March 16, 2003 (Supp. 03-1). Section repealed; new Section made 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).