1. (1) All drug trays and kits must be prepared by the pharmacy prior to release from the central pharmacy except that trays and kits may be prepared from floor-stock by an LIP who administers the drug or by authorized hospital staff in the case of emergency use if:

   1. (a) The pharmacy and appropriate hospital departments jointly develop guidelines for the proper use, preparation, and security for the trays or kits; and
   2. (b) The pharmacy has a quality assurance program for monitoring the proper use, preparation and security of the kits.
2. (2) A pharmacist must verify the accuracy and secure the contents of each tray or kit prepared in the pharmacy prior to release from the central pharmacy.

Statutory/Other Authority

ORS 689.205

Statutes/Other Implemented

ORS 689.155

History

BP 3-2010, f. 4-29-10, cert. ef. 4-30-10