Authority: IC 25-26-13-4

Affected: IC 25-26-13-17

Sec. 8. (a) During such times as an institutional pharmacy is closed and unattended by a pharmacist, the drugs may be obtained for patient use as outlined in this section.

(b) Cabinets, including mechanical storage devices for dispensing drugs, are locked or secured enclosures located outside the pharmacy licensed area, to which only specifically authorized personnel may obtain access by key, combination, or security code, password, or other method of positively identifying an individual, and are sufficiently secure to deny access to unauthorized persons. The qualifying pharmacist and/or pharmacist in charge shall, in conjunction with the appropriate committee of the institutional facility, develop inventory listings of the drugs to be included in such cabinets and shall ensure the following:

1. (1) Such listed drugs, properly labeled, are available therein.
2. (2) Only prepackaged drugs (meaning that no repackaging is required at the time of removal for an individual patient's use) are available therein, in amounts sufficient for immediate therapeutic requirements for a period not to exceed twenty-four (24) hours.
3. (3) When drugs are used, a record is made to include a written physician's order or accountability record.
4. (4) All drugs therein are reviewed by a pharmacist upon return to duty, not to exceed twenty-four (24) hours.
5. (5) There are written policies, procedures, and forms established to implement the requirements of this subsection.

(c) Whenever any drug is not available from floor supplies or cabinets, as defined in this section, and such drug is required to treat the immediate needs of a patient, such drug may be obtained from the pharmacy in accordance with the requirements of this subsection. One (1) supervisory licensed nurse in any given shift may have access to the pharmacy and may remove drugs there from. The qualifying pharmacist shall require that the removal of any drug from the pharmacy by an authorized nurse be recorded on a suitable form, which includes the name of the drug, strength, amount, date, time, and signature of nurse, and that a copy of the order shall be left with the form.

(d) Requirements for hospital emergency drug boxes, drug carts, emergency kits, emergency drug kits, crash carts, drug kits, or other storage method for emergency drugs are as follows:

1. (1) Pharmacy policy and procedures shall assure the:

   1. (A) availability;
   2. (B) control; and
   3. (C) security;
2. of emergency drug carts, drug kits, or drug boxes in the pharmacy and patient care areas.

3. (2) Procedures shall include the following:

   1. (A) Determination of drugs and quantities of drugs to be included.
   2. (B) Labeling for expiration date.
   3. (C) Process for restocking the cart, kit, or box.
   4. (D) Security measures to prevent unauthorized access.

(Indiana Board of Pharmacy; 856 IAC 1-28.1-8; filed Dec 26, 2001, 2:44 p.m.: 25 IR 1638; 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)