Authority: IC 25-26-13-4

Affected: IC 25-26-13-17

Sec. 5. (a) The pharmacist in charge shall develop or be responsible for the development of a policies and procedures manual that shall be of sufficient scope and detail that pharmacists practicing in the institutional pharmacy will be able to practice effectively and safely.

(b) The manual required in this section shall be available for inspection by a member of the board or its representative.

(c) The policies and procedures manual shall contain, at a minimum, the following:

1. (1) Provisions for a continuous quality improvement committee that shall be comprised of staff members of the pharmacy, including, but not necessarily limited to, the following:

   1. (A) Pharmacists.
   2. (B) Pharmacist interns or externs.
   3. (C) Pharmacy technicians.
   4. (D) Clerical or support staff.
   5. (E) Other persons deemed necessary by the qualifying pharmacist.
2. (2) Provisions for the pharmacist in charge or designee to ensure that the committee conducts a review of quality related events at least every three (3) months.
3. (3) A process to record, measure, assess, and improve quality of patient care.
4. (4) The procedure for reviewing quality related or sentinel events.

(Indiana Board of Pharmacy; 856 IAC 1-28.1-5; filed Dec 26, 2001, 2:44 p.m.: 25 IR 1637; readopted filed Sep 26, 2008, 10:55 a.m.: 20081015-IR-856080346RFA; readopted filed Dec 1, 2014, 8:33 a.m.: 20141231-IR-856140392RFA; readopted filed Oct 6, 2020, 12:03 p.m.: 20201104-IR-856200443RFA; readopted filed Feb 15, 2024, 1:16 p.m.: 20240313-IR- 856230795RFA)