- a) The hospital shall have pharmaceutical services that meet the needs of the patients. This service shall include a pharmacy directed by a registered pharmacist and may have a drug storage area under pharmacy supervision.
- b) A pharmacy or pharmaceutical policy and procedure manual, developed by the Pharmacy and Therapeutics Committee, shall identify the Service (system) and manner of operations that minimize drug errors.
- c) The service shall be under the direction of a registered pharmacist employed by the hospital on a full-time, a part-time or consulting basis. Responsibilities of the pharmacist must be identified in the Policy and Procedure Manual or other document and administered in accordance with accepted professional principles.
- d) A pharmacy shall be staffed at all times by a registered pharmacist during open hours. At all other times, the pharmacy shall be locked. Provisions must be made for a pharmacist or pharmaceutical service on call during times when the pharmacy is not open.
- e) When a pharmacist is absent from the hospital, a registered professional nurse may have access to the pharmacy. The nurse may obtain a single dose, manufacturer's original package, or container prepackaged under the supervision of a pharmacist of a drug or medication, necessary to administer to a patient in carrying out treatment and medication orders of a prescriber. A signed receipt for the drugs and medicines removed shall be left for the pharmacist.
- f) Automated dispensing and storage systems for the storage and supply of drugs, used in the facility, shall be stocked only under the supervision of a pharmacist. They shall be securely locked, shall provide a record of what was supplied, to whom and for which patient. The drugs contained therein may be released from the machines only by a nurse, APRN, physician assistant, physician, pharmacist, or other designated health care professional as identified by the hospital's pharmacy and therapeutics committee.
- g) All drugs and medicines shall be stored and dispensed in accordance with applicable State and Federal laws and regulations.
- h) All compounding, packaging, and dispensing of drugs and biologicals shall be under the supervision of a pharmacist and performed consistent with State and federal laws.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)