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DEPARTMENT POLICY POLICY RESCINDED RELATED REVIEWED/ EFFECTIVE NEXT REVIEW STATUS
UNIT NO. TITLE POLICY(IES) POLICY(IES) REVISED DATE DATE
Pharmacy Certification Sheet
Pharmacy 101 Purpose of Policy and Procedure Manual 03/23/2018 12/1/1994 03/23/2021
Pharmacy 201 Mission Statement 03/23/2018 12/1/1994 03/23/2021
Pharmacy 202 Integration of Pharmacy Services into the 03/23/2018 6/1/2007 03/23/2021
Hospital Organization
Pharmacy 203 Pharmacy Organization Plan 03/23/2018 2/1/1995 03/23/2021
Pharmacy 301 Scope of Service 03/23/2018 2/1/1995 03/23/2021
Pharmacy 302 Pharmacy Staffing 03/23/2018 2/1/1995 03/23/2021
Pharmacy 303 Certification of Funds: Pharmacy Stock 03/23/2018 2/1/1995 03/23/2021
Inventory Requisitions
Pharmacy 304 Patient Confidentiality and Data Security 03/23/2018 5/1/2006 03/23/2021
Pharmacy 305 Pharmacy Staff Confidentiality Attestation 03/23/2018 5/1/2006 03/23/2021
Pharmacy 306 Pharmacy Key Control 03/23/2018 2/1/1995 03/23/2021
Pharmacy 307 Orientation: Pharmacy Personnel 03/23/2018 2/1/1995 03/23/2021
Pharmacy 308 Committee Membership 03/23/2018 2/1/1995 03/23/2021
Pharmacy 309 Poison Control and Antidotes 03/23/2018 2/1/1995 03/23/2021
Pharmacy 310 Infection Control in the Pharmacy 03/23/2018 2/1/1995 03/23/2021
Pharmacy 312 Break Periods 03/23/2018 2/1/1995 03/23/2021
Pharmacy 313 Dress and Grooming Codes 03/23/2018 2/1/1995 03/23/2021
Pharmacy 314 Pharmacy Staff Meeting 03/23/2018 2/1/1995 03/23/2021
Pharmacy 315 Continuing Education for Pharmacy Staff 03/23/2018 2/1/1995 03/23/2021
Pharmacy 317 Staff Emails 03/23/2018 02/26/14 03/23/2021
Pharmacy 401 Job Descriptions 03/23/2018 2/1/1995 03/23/2021
Pharmacy 402 Absenteeism 03/23/2018 2/1/1995 03/23/2021
Pharmacy 403 Pharmacy Licenses and Registrations 03/23/2018 2/1/1995 03/23/2021
Pharmacy 501 Pharmacy and Therapeutics Committee 03/23/2018 5/1/1989 03/23/2021
DEPARTMENT POLICY POLICY RESCINDED RELATED REVIEWED/ EFFECTIVE NEXT REVIEW STATUS
UNIT NO. TITLE POLICY(IES) POLICY(IES) REVISED DATE DATE
Pharmacy 502 Drug Formulary 03/23/2018 8/4/1999 03/23/2021
Pharmacy 503 Generic Substitution 03/23/2018 12/1/1994 03/23/2021
Pharmacy 504 Investigation Drugs 03/23/2018 12/1/1994 03/23/2021
Pharmacy 505 Sample Drugs 03/23/2018 12/1/1994 03/23/2021
Pharmacy 601 Procurement of Drugs 03/23/2018 6/1/2007 03/23/2021
Pharmacy 602 Pharmacy Inventory Control 03/23/2018 2/1/1995 03/23/2021
Pharmacy 605 Loan and Borrow of Pharmaceuticals 03/23/2018 3/25/1995 03/23/2021
Pharmacy 606 Detecting of Deteriorating Drug 03/23/2018 6/1/1997 03/23/2021
Pharmacy 607 Disposition of Expired Drugs 03/23/2018 9/1/1989 03/23/2021
Pharmacy 608 Drug Return Policy 03/23/2018 2/1/1995 03/23/2021
Pharmacy 609 Drug Recall 03/23/2018 12/1/1994 03/23/2021
Pharmacy 610 Storage and Security of Drugs 03/23/2018 2/1/1995 03/23/2021
Pharmacy 611 Refrigeration of Drugs 03/23/2018 2/1/1995 03/23/2021
Pharmacy 612 Blood Derivatives-Albumin 03/23/2018 2/1/1995 03/23/2021
Pharmacy 613 Concentrated Intravenous Electrolytes 03/23/2018 2/1/1995 03/23/2021
Pharmacy 614 Radioactive Medications and Contrast Media 03/23/2018 2/1/1995 03/23/2021
Pharmacy 615 Radioactive Materials-Ordering, Receiving, and 03/23/2018 6/1/2007 03/23/2021
Handling
11/27/19 11/22
Pharmacy 616 Automated Dispensing Machines - Inspection 03/23/2018 10/23/2017 03/23/2021
1/22/20
And Inventory
Pharmacy 701 Medication Orders 03/23/2018 2/1/1995 03/23/2021
Pharmacy 702 Metric System 03/23/2018 1/1/1995 03/23/2021
Pharmacy 703 High Risk/High Alert Medication 03/23/2018 6/4/2007 03/23/2021
Pharmacy 704 Look-Alike/Sound-Alike Medications 03/23/2018 6/4/2007 03/23/2021
Pharmacy 705 In-Patient Dispensing 03/23/2018 2/1/1995 03/23/2021
DEPARTMENT POLICY POLICY RESCINDED RELATED REVIEWED/ EFFECTIVE NEXT REVIEW STATUS
UNIT NO. TITLE POLICY(IES) POLICY(IES) REVISED DATE DATE
Pharmacy 706 Review, Verification, Interpretation of 03/23/2018 1/1/1995 03/23/2021
Medication Orders
Pharmacy 707 Patient's Profile 03/23/2018 6/30/2007 03/23/2021
Pharmacy 708 Labeling Standard for Medications 03/23/2018 9/23/2005 03/23/2021
Pharmacy 709 Unit Dose Policy 03/23/2018 5/1/1989 03/23/2021
Pharmacy 710 Pharmacy Compounding Policy 03/23/2018 6/30/2007 03/23/2021
Pharmacy 711 Off-Island Medications 03/23/2018 2/1/1995 03/23/2021
Pharmacy 713 Medication Administration 03/23/2018 2/1/1995 03/23/2021
Pharmacy 714 Uniform Drug Administration Schedule 03/23/2018 2/1/1995 03/23/2021
Pharmacy 715 Automatic Medication Stop Order 03/23/2018 2/1/1995 03/23/2021
Pharmacy 716 Patient's Own Medication 03/23/2018 3/1/2003 03/23/2021
Pharmacy 717 In-Patient Self-Administration of Medication 03/23/2018 2/1/1995 03/23/2021
Pharmacy 718 Bedside Storage of Medication 03/23/2018 6/1/2007 03/23/2021
Pharmacy 720 Pharmacy Repackaging of Unit Dose and Unit 03/23/2018 6/1/2007 03/23/2021
Dose
Pharmacy 721 Decreasing Medication Errors 03/23/2018 6/1/2007 03/23/2021
Pharmacy 722 Pediatric Dosing 03/23/2018 6/1/2007 03/23/2021
Pharmacy 723 Enhancing Pharmaceutical Services at Skilled 03/23/2018 6/10/2008 03/23/2021
Nursing Unit
Pharmacy 724 Monitoring Effects of New Medications on 03/23/2018 2/10/2012 03/23/2021
Patients
Pharmacy 725 Beyond Use Dating - Oral Solutions 03/23/2018 01/21/2016 03/23/2021
Pharmacy 726 Titrating/Tapering Of Medications 03/23/2018 10/23/2017 03/23/2021
Pharmacy 727 Medication Administration Record Document 03/23/2018 10/23/2017 03/23/2021
Pharmacy 728 Psychotropic Medications 03/23/2018 10/23/2017 03/23/2021
Pharmacy 729 Beyond Use Dating - Topical Irrigation Solutions 5/3/2018 5/16/2018 5/2021
Pharmacy 730 Medication Reconciliation 01/22/2020 01/22/2020 01/22/2023
Pharmacy 801 Policy Statement on the Compounding of Sterile 03/23/2018 8/23/2006 03/23/2021
Parenteral Admixtures
DEPARTMENT POLICY POLICY RESCINDED RELATED REVIEWED/ EFFECTIVE NEXT REVIEW STATUS
UNIT NO. TITLE POLICY(IES) POLICY(IES) REVISED DATE DATE
Pharmacy 802 Parenteral Admixtures- Ordering and Handling 03/23/2018 8/23/2006 03/23/2021
Pharmacy 803 Aseptic Technique-Preparing for Mixing IV 03/23/2018 6/1/2007 03/23/2021
Admixture
Pharmacy 804 Aseptic Technique- Syringe Manipulation 03/23/2018 6/1/2007 03/23/2021
Pharmacy 805 Aseptic Techniques-Reconstitution and Transfer 03/23/2018 2/1/1995 03/23/2021
of a Drug to a Parenteral Solution
Pharmacy 806 Discontinued IV Solutions 03/23/2018 6/30/2007 03/23/2021
Pharmacy 807 Laminar Air-Flow Hood and Biologic Safety 03/23/2018 8/23/2006 03/23/2021
Cabinet
Pharmacy 808 USP 797 Compliance Policy 03/23/2018 06/04/2014 03/23/2021
Pharmacy 809 Cytotoxic Drugs-Handling/Ordering/Preparing 03/23/2018 3/26/2005 03/23/2021
Pharmacy 810 Cytotoxic Drugs Storage 03/23/2018 6/5/2007 03/23/2021
Pharmacy 811 Disposal of Cytotoxic Waste 03/23/2018 6/5/2007 03/23/2021
Pharmacy 812 Cytotoxic Drug Spillage Handling 03/23/2018 6/5/2007 03/23/2021
Pharmacy 813 Total Parenteral Nutrition-TPN & PPN 03/23/2018 6/5/2007 03/23/2021
Pharmacy 814 Handling of Multi-Dose Vial of Injectable Drugs 03/23/2018 6/4/2007 03/23/2021
Pharmacy 815 Immediate use of IV Prepared by Nurse in 03/23/2018 8/4/1999 03/23/2021
Nursing Units
Pharmacy 816 Extravasation of Drugs and Antidotes 03/23/2018 12/31/1994 03/23/2021
Pharmacy 901 Controlled Substances General Policy 03/23/2018 1/31/1995 03/23/2021
Pharmacy 902 Registration for Controlled Substances 03/23/2018 1/31/1995 03/23/2021
Pharmacy 903 Controlled Substances: Inpatient Dispensing 03/23/2018 1/31/1995 03/23/2021
Pharmacy 904 Controlled Substances: Outpatient Dispensing 03/23/2018 1/31/1995 03/23/2021
Pharmacy 905 Controlled Substances-DEA & CSR Licensure 06/08/2007 5/16/2018 5/2021
Pharmacy 906 Controlled Substances- Verification of 03/23/2018 6/8/2007 03/23/2021
Administration Record Entries
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