N.H. Admin. Code § Saf-C 5918.03

Current through Register No. 36, September 5, 2024

Section Saf-C 5918.03 - MRH Responsibilities

(a) The MRH shall develop policies and procedures to address the supply and distribution of controlled drugs to agreement units pursuant to Saf-C 5918.01(h) through (j).

(b) The policies and procedures shall specifically address, but not be limited to, such issues as:

(1) Initial stocking;

(2) Returns;

(3) Drug kit replacement;

(4) Recordkeeping requirements;

(5) Drug losses;

(6) Security of the drug kits; and

(7) Reports.

(c) At the time of the initial distribution of the drug kit(s) to the UCDC, the pharmacy shall review the policies and procedures with the UCDC and document the following:

(1) The UCDC name;

(2) The unit;

(3) The date, time, and place of meeting; and

(4) The topics covered.

(d) Controlled drugs shall only be supplied in drug kits that meet the following requirements:

(1) The quantity of controlled drugs contained in the drug kits and the contents of the proof of use sheet shall be determined jointly by the pharmacy and the medical director;

(2) The pharmacy shall document the contents of each drug kit;

(3) All controlled drug kits shall be prepared and sealed by the pharmacy; and

(4) Each drug kit shall contain the following information on the outside of the container:

a. The name of the MRH;

b. The expiration date of the drug kit; and

c. The specific identification number of the drug kit.

(e) Replacement drug kit(s) shall be obtained directly from the pharmacy.

(f) A specified number of replacement drug kit(s) may be stored in the MRH's emergency department for purposes of restocking during times that the pharmacy might be closed.

(g) Drug kits located in the emergency department shall be stored in a locked location, separate from all other drug supplies of the emergency department.

(h) The replacement drug kits shall only be accessed by the emergency department supervisor.

(i) The sealed replacement drug kits shall be included as part of the emergency department shift change narcotic count as established by the MRH.

(j) The pharmacy shall provide the emergency department with a list of those persons, designated by the unit's UCDC, who are authorized to engage in drug kit replacement.

(k) The pharmacy shall develop a system of documentation for the emergency department to record drug kit replacement activities.

(l) Documentation in (k) above shall include:

(1) The date and time of shift counts for sealed drug kits;

(2) The number of sealed drug kits on hand; and

(3) The name of the person doing the count and the name of the witness.

(m) Utilized drug kits shall be accepted and documented in the emergency department by the shift supervisor.

(n) Utilized drug kits shall be stored in a locked area, separate from the emergency department's own inventory.

(o) A separate medications inventory sheet, for documenting utilized drug kit contents, shall be developed by the pharmacy.

(p) Upon receipt of the utilized drug kit, the contents shall be documented on the proof of use sheet by the person relinquishing the kit and the nurse supervisor or pharmacist receiving the kit.

(q) The medications inventory proof of use sheet shall be documented at each shift inventory until such time as the utilized drug kit is returned to the pharmacy.

(r) Utilized drug kits and inventory documents shall be forwarded to the pharmacy pursuant to facility procedures.

N.H. Admin. Code § Saf-C 5918.03

(See Revision Note at chapter heading for Saf-C 5900) #8520, INTERIM, eff 12-16-05, EXPIRED: 6-14-06

New. #9779-A, eff 9-8-10

Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12790, Effective 5/24/2019, Expires 5/24/2029.