Okla. Admin. Code § 535:15-16-4

Current through Vol. 42, No. 4, November 1, 2024

Section 535:15-16-4 - Policies and procedures for use of emergency medication kit drugs

(a) The drugs in the emergency medication kits shall remain the property of an Oklahoma licensed pharmacy.

(b) Only one Oklahoma licensed pharmacy may provide emergency medication kits to each facility.

(c) Emergency medication kits maintained by an Oklahoma licensed pharmacy within the facility shall be approved by the medical director of the facility and the facility's consultant pharmacist on at least an annual basis.

(d) Medications may be administered from the facility's emergency medication kit only upon a prescriber's order for the emergency medication; and must be administered by a licensed nurse, physician, or physician's assistant.

(e) The facility licensed nurse shall

(1) verbally transmit the order for an emergency drug requiring access to the emergency medication kit to an Oklahoma licensed pharmacist who is an employee of the Oklahoma licensed pharmacy and is physically located within the United States at the time the order is transmitted prior to the removal of a medication from the emergency medication kit,

(2) or may electronically transmit the order to an Oklahoma licensed pharmacy and located within the United States following all federal and state regulations and rules only if the Oklahoma licensed pharmacy is utilizing technology which requires the Oklahoma licensed pharmacist to release the medication from the emergency medication kit by electronic means.

(f) The facility and Oklahoma licensed pharmacy shall have a written agreement that clearly states these drugs should not be used for routine use, but for emergency use and the need of the patient for urgent care.

(1) This written agreement shall contain a policy for record keeping of medications removed from the emergency medication kit.

(2) The Oklahoma licensed pharmacy shall require the facility to maintain a readily retrievable log of usage from the emergency medication kit which shall include for each dose administered from the emergency medication kit, at a minimum:

(A) Name of ordering prescriber

(B) Date and time of order,

(C) Facility resident's name,

(D) Medication name and strength,

(E) Name of person administering medication, and date and time administered,

(F) Such log shall be maintained in the facility and the Oklahoma licensed pharmacy and shall be available for Board inspection.

(3) The facility and Oklahoma licensed pharmacy shall document the nature of the emergency.

(4) Name of person verbally notifying the Oklahoma licensed pharmacy shall be recorded by the Oklahoma licensed pharmacy,

(5) The agreement shall document the protocol for handling and storage of these drugs by authorized employees and shall be approved by the Oklahoma licensed pharmacy manager.

(6) The Oklahoma licensed pharmacy shall review the agreement, recordkeeping and drug storage and handling at a minimum of annually.

(7) The facility and Oklahoma licensed pharmacy shall have a policy on replacement of medication in a timely manner.

(A) Replacement of controlled dangerous substances (CDS) in the emergency medication kit in a facility may be done by a licensed nurse employed at the facility or an employee of the Oklahoma licensed pharmacy.

(B) Replacement of the non-controlled drugs from the licensed Oklahoma pharmacy in the emergency medication kit may be done by a licensed nurseemployed at the facility or an employee of the Oklahoma licensed pharmacy.

(g) The Oklahoma licensed pharmacy shall maintain the following records for each facility remote site where an emergency medication kit is maintained:

(1) A log of facilities for which the Oklahoma licensed pharmacy provides emergency medication kits;

(2) A log of medications stored in each emergency kit at each facility;

(3) The Oklahoma licensed pharmacy shall require the facility to maintain a log of usage from the emergency medication kit; and,

(4) The log of usage from the emergency medication kit shall be auditable and maintained in a readily retrievable manner by the facility.

(h) Expired medications shall be removed from emergency supply by a licensed nurse employed at the facility or an employee of the Oklahoma licensed pharmacy; and shall not be dispensed or administered.

(i) Controlled Dangerous Substances (CDS) may be maintained only in a medication kit that is separate from Non-Controlled Dangerous Substances or within an electronic medication dispensing machine, if allowed, in accordance with Oklahoma Bureau of Narcotics and the federal Drug Enforcement Administration laws and rules.

(j) Emergency medication kits that do not contain controlled dangerous substances may be maintained in an electronic system or in a secure emergency medication kit. A list of drugs in the emergency medication kit shall be attached to the same.

(k) A record of transactions involving the controlled substance emergency medication kit shall be maintained for two (2) years in a readily retrievable manner by the Oklahoma licensed pharmacy and facility. This transaction record is separate from the prescription record which must be maintained for a minimum of 5 years.

Okla. Admin. Code § 535:15-16-4

Added at 29 Ok Reg 1641, eff 7-12-12; Amended at 30 Ok Reg 2013, eff 7-25-13

Amended by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015.

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/11/2022

AGENCY NOTE: Contact Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBNDDC) and the federal Drug Enforcement Agency (DEA) - No controlled dangerous substances (CDS) are allowed unless and until approved by both OBNDDC and DEA.