R4-23-659. Administration of Drugs

A. Self-administration. A hospital shall not allow self-administration of medications by a patient unless the Director of Pharmacy or pharmacist-in-charge, in consultation with the appropriate department personnel and medical staff committee, develops, implements, reviews, and revises in the same manner described in R4-23-653(A) and complies with policies and procedures for self-administration of medications by a patient. The policies and procedures shall specify that self- administration of medications, if allowed, occurs only when: 1. Specifically ordered by a medical practitioner, and 2. The patient is educated and trained in the proper manner of self-administration. B. Drugs brought in by a patient. If a hospital allows a patient to bring a drug into the hospital and before a patient brings a drug into the hospital, the Director of Pharmacy or pharmacist-in- charge shall, in consultation with the appropriate department personnel and medical staff committee, develop, implement, review, and revise in the same manner described in R4-23- 653(A) and comply with policies and procedures for a patient- owned drug brought into the hospital. The policies and procedures shall specify the following criteria for a patient-owned drug brought into the hospital: 1. When policy allows the administration of a patient- owned drug, the drug is not administered to the patient unless: a. A pharmacist or medical practitioner identifies the drug, and b. A medical practitioner writes a medication order specifying administration of the identified patient- owned drug; and 2. If a patient-owned drug will not be used during the patient’s hospitalization, the hospital pharmacy’s personnel shall: a. Package, seal, and give the drug to the patient’s agent for removal from the hospital; or b. Package, seal, and store the drug for return to the patient at the time of discharge from the hospital. C. Drug samples. The Director of Pharmacy or pharmacist-in- charge is responsible for the receipt, storage, distribution, and accountability of drug samples within the hospital, including developing, implementing, reviewing, and revising in the same manner described in R4-23-653(A) and complying with specific policies and procedures regarding drug samples.