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Name of Policy:

-F loor
- Stock
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

Ncw policy proposal x Minor11echnical revision of existing policy


Major revision of existing policy Reaffinnation of existing policy

{A) Policy Statement

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.

{B) Purpose of Policy

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.

5. The inspection is to include, but not be limited to:

a. A check for outdated items


b. A check for proper storage conditions
c. A refrigerator log must be provided to pharmacy personnel during periodic inspections.
d. A check for overstock, and removal thereof
e. A check for unauthorized items, and removal thereof
f. A check for cleanliness
g. Verification of narcotic counts (if applicable)
h. Sample drugs are properly stored and maintained (if applicable)
i. Investigational drugs are properly stored (if applicable)
J. Reference materials arc available, and current
k. Emergency drugs are both adequate and in proper supply

STOCK REQUESTS FROM NON-NURSING UNITS


Policy 3364-133-05
Floor Stock
Page 2

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.

REQUEST FOR TAX FREE ETHYL ALCOHOL

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.

Approved by: Review/Revision Date:


5194

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7196

Director of Pharmacy
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7104

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7114

Rnie" Rei isio11 Completed By;


Pharmacy

Next Review Date: October l, 2014


Policies Superseded by This Policy:
It is the responsibility of the reader to verify with the responsible agent that this is the most current version of the policy.

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