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Policy Number: 3364-133-05 .TOLEo6
Oepurtment: Pharmacy
Approving Officer: Vice President Clinical Services
Responsible Agent: Director of Pharmacy
Effective Date: 7/ 1/2014
Scop e: University of Toledo Medical Center
lnitial Effective Date: January I, 1993
The Department of Pharmacy will provide each nursing unit/Clinic supplies as determined by the responsible
physician, Pharmacy Director, Medical Director and Manager of that unit. Floor supplies are minimized
whenever possible.
To maintain a constant and controlled supply of agreed upon drugs, controlled substances and supplies on all
nursing units/ clinics that keep drng stock supplies.
(C) Procedure
1. A standardized form approved by responsible physician, pharmacy director, medical director or manager of
the unit/clinic will contain a list of approved stock. All other requests must be ordered patient specific on
the requisition form.
2. The clinic will be responsible for billing all medications to the patient
3. All nursing units/Clinic that keep drug stock supplies shall be inspected periodically by a representative of
the pharmacy staff. A standard inspection form is used to document each inspection. Repeated problems
will be reported to the nursing manager/supervisor for each unit.
4. Controlled substances and select high dollar/high risk medications as determined by responsible parties
listed above will be signed and billed via single sheets.
Supplies for outpatient and ancillary departments, such as Radiology, Clinical Laboratory, and research
laboratories may be obtained by submitting an approved form . Such requests must be approved by the
department head or an authorized representative. The name of the department and account number must be
provided. Acknowledgement of receipt will occur.
Ethyl Alcohol for laboratory use may be obtained from the pharmacy by submitting in triplicate a request for
supplies on form MCO #B2 l 0. The request must be approved by the department head. The name of the
department and the account number must be in the upper right hand corner. Acknowledgement of receipt must
appear in the lower left comer.
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Director of Pharmacy
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