Attachment 9 - 119-01 PHARMACY SERVICE.pdf

1. PURPOSE: To establish Pharmacy Service hours of operation and other general Pharmacy policies and procedures.

2. POLICY: It is the Memphis VA policy to provide comprehensive, collaborative, and patient-centered pharmaceutical services. The Pharmacy Service shall be organized to combine the best elements of pharmacy practice management, technology, research and education to provide patient centered pharmacy services. The Pharmacy Service will strive to ensure that all patients receive appropriate, safe and economical drug therapy, therapeutic monitoring, efficient preparation, dispensing and delivery of medications, and avoidance of unnecessary adverse effects. The Memphis VA Pharmacy, consistent with Federal law, will participate in the state prescription monitoring program. The Pharmacy Service is responsible for compliance with Joint Commission Standards, VA Standards and customer satisfaction. The VA pharmacies are locked, secure areas and only authorized persons may enter.

3. RESPONSIBILITY: The Chief, Pharmacy Service is responsible for carrying out policy and for the performance of all administrative and professional aspects of Pharmacy Service operations.

4. PROCEDURE:

a. All therapeutic and diagnostic drugs and medicines for patient care and treatment will be dispensed by Pharmacy Service. Additionally, general medical supplies, prosthetic medical supplies, and dietary supplements for ambulatory patients will be dispensed by Pharmacy Service.

b. All drugs and medications for individual patients will be dispensed by Pharmacy Service when ordered by an authorized practitioner via an approved medication ordering mechanism. Approved methods of ordering medications are through direct electronic order entry into the Computerized Patient Record System (CPRS) by an authorized practitioner using the POE/RR (Provider Order Entry/Results Reporting) option, or using another approved ordering mechanism. CPRS is the expected mechanism for ordering medications for patients.

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 119-01

Dated: October 16, 2017

Expires: October 15, 2020

Title: PHARMACY SERVICE

36C24920R0114 - Attachment 9

(1) Authorized practitioners are those staff members who have clinical privileges (and scope of practice statements where appropriate) currently approved by the Clinical Executive Board. Electronic signatures are accepted identification when medication orders are entered into the hospital computer by authorized practitioners using the POE/RR computer option. Electronic orders for medications identified as controlled substances by the Drug Enforcement Agency (DEA) will require dual authentication utilizing the practitioner’s Personal Identity Verification (PIV) card.

(2) Medications may be administered by registered nurses and licensed practical nurses who are medical center employees and other individuals on the staff with appropriate clinical privileges or scope of practice.

(3) All medications administered to hospitalized medical center patients will be appropriately documented in the patient's electronic medical record via Bar Code Medication Administration (BCMA) by the BCMA-trained individual involved in the administration of the medication.

c. All prescriptions will be numbered and dated by the computer. The pharmacist will insure appropriate control data is documented. Data portraying all current medications for ambulatory patients will be processed by and stored in the computer by patient name.

d. Prescriptions written at another VA health care facility may be evaluated and reordered if necessary by a provider in the Emergency Department or the patient’s primary care provider. Patients are then referred to Pharmacy Service for medication dispensing.

e. Veterans with an approved episode of care (i.e. Choice Act) at an outside medical facility may present prescriptions to the Outpatient Pharmacy for medication dispensing. The Veteran should provide an authorization of care along with the prescription(s).

f. The pharmacy is authorized to mail prescriptions for Controlled Substances, including Schedule II and Schedule III Narcotics.

g. Entrance to the pharmacy will be limited to authorized personnel.

h. A pharmacist will be present and in charge at all times when the pharmacy is open. The hours of operation are as follows:

(1) The Outpatient Pharmacy (Bed Tower, Room GB1100), is open from 8:30 a.m. to 5:30 p.m., Monday through Friday (except Holidays) and from 9:00 a.m. to 1:00 p.m. on Saturdays and selected Holidays.

(2) The Spinal Cord Injury/Mailout Pharmacy (Spinal Cord Injury Building, Room 2A-122), is open from 8:30 a.m. to 5:00 p.m., Monday through Friday (except Holidays).

(3) The Inpatient Pharmacy (Bed Tower, DB1102) is open 24/7.

(4) The Pharmacy Office (Bed Tower, BWG33) is open from 8:00 a.m. until 4:30 p.m., Monday through Friday (except Holidays).

(5) The Surgical Intensive Care Section (Bed Tower, Room G339) is open from

7:00 a.m. through 3:30 p.m. daily as staffing permits.

(6) The Medical Intensive Care Section (Bed Tower, Room F200) is open from

7:00 a.m. through 3:30 p.m. daily as staffing permits.

(7) The Oncology Pharmacy Section (Bed Tower, Room D416) is open from 8:00 a.m. through 4:00 p.m., Monday through Friday (except Holidays).

(8) The Emergency Department Pharmacy Section is open from 11:00 a.m until

11:30 p.m., Monday through Saturday, and 1:00p.m. through 9:30 p.m. on Sundays when staffing permits (except Holidays).

i. After Hours Medication Availability for Ambulatory Patients:

(1) Non-controlled and controlled medications are maintained in the automated drug dispensing cabinet system, located in the Emergency Department, and are monitored and restocked on a routine basis by Pharmacy Service staff. Medications should be dispensed from this system only to patients with acute medical needs.

(2) Medications for discharged Emergency Department patients are processed by Pharmacy Service after the provider enters the orders into CPRS.

j. Security:

(1) Authorized persons who are permitted to enter the Inpatient Section of Pharmacy Service will come to door Bed Tower, Room DB1102 for admittance.

(2) Authorized persons who are permitted to enter the Pharmacy Office will come to door Bed Tower, Room BWG33 for admittance.

(3) Authorized persons who are permitted to enter the Outpatient Section of Pharmacy Service will come to door Bed Tower, Room GB1100 for admittance.

(4) At all times when authorized persons (other than pharmacy employees) are in the pharmacy, they must be continually in the presence of a Pharmacy employee. At no time may authorized persons in the Pharmacy be left alone or unattended.

Pharmacy students on rotations and/or work study students are authorized individuals who are exempt from this requirement.

(5) Unauthorized persons may not gain entrance into the Pharmacy. The issuance of door keys, security cards, or numerical combination access, that allow entry into the Pharmacy Service is to be restricted by the Chief, Pharmacy Service to employees who require access. Pharmacy Service employees will gain access to Pharmacy locations by use of the PIV card and pin code (dual factor authentication).

(6) Controlled substance vaults with a day gate must have a locking mechanism. The use of an object to prop the door open or hinder the locking mechanism is prohibited.

5. REPORTING REQUIREMENTS: None.

6. RESPONSIBLE OFFICE: Pharmacy Service (119).

7. REFERENCES: VHA Handbook 1108.07.

8. RESCISSION: Medical Center Policy Memorandum 119-01, July 18, 2014.

Medical Staff Concurrence: Date: October 16, 2017

/s/

THOMAS C. FERGUSON, M.D.

Chief of Staff

/s/

DAVID K. DUNNING, MPA

Medical Center Director