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Hospital Bylaw 8Section Number / Name
Required Services Negotiable Services
69 Responsibilities ofthe hospitalpharmacy manager
The pharmacy manager must:
actively participate in the day-to-daymanagement of the
pharmacy
ensure that pharmacist and pharmacy
support personnel staffing levels arecommensurate with the
workload volumeand patient care requirements at all times,
maintain required hours of pharmacyservices.
Administrative aspects of pharmacypractice management, such
as:
writing, developing or updatingpharmacy policies and
procedures
pharmacy and therapeutics committeeand/or other pharmacy
committee(s)
financial or statistical reports.
71 Quality management Maintain ongoing quality
managementprograms related to risk reduction andcontinuous quality
improvement processesassociated with medication error
prevention.
Reporting and documenting all medicationincidents /
discrepancies.
Administrative aspects of qualitymanagement programs.
Periodic or time-limited aspects of thequality management
program.
Drug utilization evaluation.
72 Hospital pharmacypremises
After hospital pharmacy hours, all hospitalpharmacy premises
must continue to besecured against unauthorized entry of
thepremises.
No change in the personnel authorized tohave access to pharmacy
premises mayoccur.
The pharmacy premises must be maintainedto ensure that
medications are compounded,prepared, stored and dispensed under
sanitary conditions.
74 Medicationdistribution
Maintain established medication distributionsystems including
unit-dose, CIVA and sterileproduct preparation, monitored
dosageand/or individual prescription systems.
total wardstock systems are not permitted established wardstock
replacement
systems must be continued delivery of medications to patient
care
areas must be continued maintain established programs for
dispensing specialized outpatientmedications and sterile
products that arenot available from community sources.
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Hospital Bylaw 8Section Number / Name
Required Services Negotiable Services
75 After hours service After hours pharmacy services must
bemaintained.
an established night cupboard must bemaintained
provision of an on-call pharmacist service,if established, must
be maintained.
77 Returnedmedications
Medications dispensed for administration, butnot used, must
continue to be returned topharmacy.
Sorting, determining the suitability forredispensing, returning
to stock,discarding or destroying medications.
78 Medicationprocurement /inventorymanagement
A pharmacist must supervise the purchase,acquisition and storage
of all medications forthe hospital. All legally
requireddocumentation of medication purchasesmust be continued.
All medication shipments must be deliveredunopened to the
hospital pharmacy or adesignated secure storage area.
Established medication storage and securityprocedures must be
continued.
Non-usable and expired medications must bestored in a separate
area of the pharmacyuntil final disposal.
Financial and statistical functions.Invoice, purchase order or
otherdocument sorting and filing.
Disposal of non-usable and expiredmedications.
79 Inpatient passmedications
Maintenance of an established pass-medication system. All pass
medications
must be prepared according to theestablished standard.
80 Emergencydepartmentmedications
Maintenance of established system toprovide small quantity of
urgently neededmedication to patients. All medications mustbe
prepared according to the establishedstandards.
81 Special-AccessProgrammedications
Continue to store and distribute clinical trialmedications to
patients already enrolled in anestablished protocol.
Store and distribute special-access programmedications, if
required.
Enrollment of new patients in anestablished clinical trial
medicationprotocol.
Establishment of new clinical trialmedication protocols.
82 Medicationrepackaging andcompounding
If medication repackaging or compounding isperformed, it must be
done in accordancewith the established standard and be doneunder
the supervision of a pharmacist.
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Hospital Bylaw 8Section Number / Name
Required Services Negotiable Services
83 Hospital pharmacysupport personnel
If hospital pharmacy support personnelperform nonprofessional
functions, apharmacist must be readily available toanswer questions
and provide direction andsupervision.
84 Patient medicationrecord andmedication orderreview
Maintenance and use of complete patientmedication profiles.
The accuracy of the patient medicationprofile must continue to
be verified by thepharmacist.
Maintenance of established process ofmedication order review and
intervention, ifrequired, by a pharmacist.
85 Medication
administration
Maintenance of the established system of
producing medication administration recordsfrom the pharmacy
medication profiledatabase.
computerized MARs cannot be changedto a manual transcription
system
86 Patient-orientedpharmacy services
Maintenance of established direct patient-care services,
including:
identifying, resolving or preventingmedication-related
problems
medication history services
medication therapy monitoring patient-specific drug and poison
informationservices,
patient medication therapy teaching orcounselling
pharmacokinetic dosage adjustments home IV therapy assessments,
if provided
Maintenance of established controlledmedication dosage
adjustment services suchas:
anticoagulant dosage adjustment total parenteral nutrition
adjustment clinical pathways that require the
pharmacist to adjust medicationsaccording to established
protocols.
Non-direct patient care services,including:
drug utilization evaluation pharmacy publications and provision
of
non-patient specific drug information
such as newsletters, inservices,formulary updates/reviews,
etc.
teaching pharmacy, nursing or otherstudents or staff
orientation, training or certificationprocedures.
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5070-Standards for Essential Services v2009.1 Page 5
Hospital Bylaw 8Section Number / Name
Required Services Negotiable Services
87 Residential careservices
Maintenance of residential pharmacyservices including:
medication distribution system pass medications for residents
new medication order review if scheduled, resident care
conferences
and medication therapy reviews
88 Documentation Maintenance of established policies
ofdocumenting in the patient's permanenthealth record
including:
medication order changes information pertaining to the drug
therapy
of the patient
