Hospital Medication Administration

(1) Medications must be administered only when ordered by a duly licensed physician, dentist, podiatrist, nurses authorized by law, or other professionally educated practitioners functioning under medical protocol and with the approval of the hospital medical staff by laws and governing board of the hospital and in accordance to state law. When medications are administered, the medication and dosage must be checked against the orders. Each dose must be properly recorded in the clinical record. (2) Written policies must be established to control the administration of toxic or dangerous drugs with specific reference to the duration of the order and dosage. (3) All medications must be administered by licensed medical or licensed nursing personnel or by other qualified personnel. (Qualified personnel under these rules means a certified or registered respiratory therapist, a radiological technologist, a nuclear medicine technologist, or a certified physician assistant practicing pursuant to a protocol approved by the medical staff of the hospital.) Such qualified personnel may only administer medication within the scope of an established protocol. (4) Legend drugs must be dispensed only by a licensed pharmacist. (5) The facility will report medication errors, drug reactions and suspected drug overmedication to the practitioner who prescribed the drugs or the on-call physician in the absence of the prescribing practitioner.