Behavioral Health Services, Inc.
Subject: Detoxification – Chemical Dependency Recovery Hospitals Policy#: 4.5.14.1
Title: Medication Management and the Role of Consultant Pharmacist
Effective Date of This Revision: January 9, 2009
Contact: Medical Director 310-679-9126
Administration
Applies to:
Officers
Other agents
Staff
Visitors
Student clinicians
Contractors
Volunteers
Subcontractors / Business Associates
BACKGROUND:
The Chemical Dependency Recovery Hospitals of BHS use medications as part of the treatment of dependencies in accordance with general accepted standards of medical practice and upon the order of the Medical Director or alternate physician.
PURPOSE:
The purpose of this document is to outline policy and procedures for the role of medication management and use of Consultant Pharmacist in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.
POLICY:
BHS recognizes that while alcoholics and drug dependent patients are at risk for becoming
addicted to other drugs, properly controlled use of medication may be instrumental in recovery by helping patients through withdrawal syndromes and in continuing abstinence from alcohol and other drugs.
The use of medications for conditions other than alcoholism or drug dependencies shall also conform to generally accepted medical practice and BHS policies and procedures. Medications shall be handled in accordance with the licensing regulations of the California State Board of Pharmacy, the CDRH regulations under Title 22, and the Drug Enforcement Administration.
Role of Consultant Pharmacist
Each Chemical Dependency Recovery Hospital shall, with the assistance of a consultant
licensed pharmacist, develop and oversee the implementation of policies and procedures
governing the management of medications for patients. These policies and procedures will include the safe storage, preparation, distribution, and administration of drugs in accordance with applicable federal, state, and local laws and regulations. After review and approval by the Pharmacy and Therapeutics Committee of the facility, policies and procedures shall be approved by the Medical Director, administrator and the governing body and shall be implemented by the facility staff. The Consultant Pharmacist shall provide routine quality assurance monitoring and participate as a member of the Pharmacy and Therapeutics Committee.
PROCEDURE:
A licensed pharmacist shall be retained as a consultant by the facility to review the drug
regimen. He or she will review randomly selected patient records each month. These reviews shall be documented in writing on the Pharmacist Consultation Report. Any long-term residential patients shall be reviewed at least quarterly.
The Consultant Pharmacist’s review of the drug regimen of each selected patient shall include the following:
All drugs currently ordered
Appropriateness of drug therapy
Patient’s response to drug therapy
Completeness of medication administration records
A review of laboratory test results, nurse’s notes and physician’s progress notes as may
pertain to medication therapy.
The Consultant Pharmacist shall also inspect medication areas on a monthly basis and
document inspection in Pharmacy Inspection Report. These inspection reports shall verify that the following requirements are met:
Disinfectants and drugs for external use shall be stored separately from internal and
injectable drugs.
Drugs requiring special conditions for storage to assure stability shall be properly stored.
Outdated drugs shall not be stocked.
Distribution and administration of controlled drugs shall be adequately documented, according to facility policy.
Emergency drugs shall be kept in adequate supply.
An emergency box that meets the following requirements shall be maintained:
o The emergency supply shall be made up in consultation with a physician.
o The emergency supply shall be readily available to staff, but not accessible to
patients.
o The contents of the emergency box shall be appropriate to the needs of the patients.
o The emergency supply shall be inspected after use and at least monthly to remove
deteriorated and outdated drugs and assure completeness of content.
The physician responsible for the emergency supply shall provide a list of its contents and
appropriate instructions for use. The physician responsible for the emergency supply shall
authenticate the list of its contents with his or her signature.
The Consultant Pharmacist shall present the Pharmacist Chart Review and the Pharmacy
Inspection Report to the Administrator, the Medical Director and the Director of Nursing (DON) on a monthly basis. Any major irregularities in the dispensing and administration of medications and other matters relating to review of the drug regime shall be summarized in this monthly report. At the end of each quarter, the Pharmacist will prepare a Quality Assurance Summary report in addition to the usual monthly report. This report shall serve as a basis to measure the
quality of pharmaceutical services provided.
The written quarterly report shall be presented to the Pharmacy and Therapeutics
Committee for review. Corrective actions shall be taken whenever problems are identified.
The quarterly pharmacist report shall also be presented to the Pharmacy and Therapeutic Committee for review and discussion.
Corrective actions shall be taken wherever problems or quality issues are identified.
The Consultant Pharmacist shall assist the administration to provide cost effective service and
shall make recommendations about those methods that are economical without compromising quality care.
Additional responsibilities of the Consultant Pharmacist shall include direction or active
participation in the following:
Establishing specifications for the procurement of all drugs, chemicals, and biologicals
Participating in the development of a facility formulary, the existence of which does not
preclude the use of unlisted drugs, and of a formulary system to be approved by the
appropriate members of the professional staff.
Dispensing drugs and chemicals, including making provisions for dispensing drugs and
chemicals in an emergency.
Filling and labeling all drug containers issued to departments from which medications are to be administered (in cooperation with the contract pharmacy).
Implementing the decisions made by relevant professional staff committees concerning drug usage.
Maintaining and keeping available in the pharmacy and patient care areas, the approved stock of antidotes and other emergency drugs.
Ensuring that up-to-date pharmaceutical reference material is provided so that appropriate staff will have adequate information concerning drugs. The Consultant Pharmacist shall also have access to current editions of text and reference books, which pertain to the practice of pharmacy.
Reviewing and providing comment on the criteria established for medication management portion of the facility’s quality improvement program.
The Consultant Pharmacist may participate in education programs, when appropriate, including the following:
Drug abuse education programs conducted by the facility.
Public education and information programs relative to the services of the facility.
A medication administration training program that is approved by a physician that shall be provided for clinical staff who administer medications. The content of the training program shall be in writing, be available for review, and include at least the following:
o Appropriate information about the nature of the drugs to be administered
o Supervised training in the administration of medications
o Instruction in the expected actions and side effects of the drugs to be administered.
Staff development programs for the clinical staff concerning pharmaceutical issues.
Detoxification - CDRHs Medication Management and Role of
Consultant Pharmacist
Policy # 4.5.14.1
Reviewed by: Medical Director, Directors of Nursing Review Date: 1/29/2009
Approved by: Board of Directors Approval Date: 1/29/2009
Effective Date 1/29/2009
Supersedes Policy/Date: 4.5.15. – 4.5.15.1
