657—7.12 (124,126,155A) Drugs dispensed to patients as a result of an emergency room visit. In those facilities with 24-hour pharmacy services, only a pharmacist or prescribing practitioner may dispense any drugs to an outpatient, including emergency department patients. In those facilities without 24-hour pharmacy services, or in those facilities without outpatient pharmacy services or when the facility’s outpatient pharmacy is closed, the following procedures shall be observed in dispensing drugs:
	 7.12(1) Patients examined in emergency room. Drugs shall be dispensed only to patients who have been examined in the emergency room.
	 7.12(2) Accountability. Drugs shall be dispensed only in accordance with the system of control and accountability for drugs administered or dispensed from the emergency room.
	  a.   	 The system shall be developed and supervised by the pharmacist in charge and the facility’s emergency department committee, or a similar group or person responsible for policy in that department.
	  b.   	 The system shall identify drugs of the nature and type to meet the immediate needs of emergency room patients.
	  c.   	 Controlled substances maintained in the emergency room are kept for use by, or at the direction of, prescribers in the emergency room. In order to receive a controlled substance, a patient must be examined in the emergency room by a prescriber who shall determine the need for the drug. It is not permissible under state and federal requirements for a prescriber to see a patient outside the emergency room setting, or talk to the patient on the telephone, and then proceed to call the emergency room and order the administration of a stocked controlled substance upon the patient’s arrival at the emergency room. A prescriber may authorize, without again examining the patient, the administration of additional doses of a previously authorized drug to a patient presenting to the emergency department within 24 hours of the patient's examination and treatment in the emergency department.
	  d.   	 In an emergency situation when a health care practitioner authorized to prescribe controlled substances is not available on site and regardless of the provisions of paragraph “c,” the emergency room nurse may examine the patient in the emergency room and contact the on-call prescriber. The on-call prescriber may then authorize the nurse to administer a controlled substance to the patient pending the arrival of the prescriber. As soon as possible, the prescriber shall examine the patient in the emergency room and determine the patient’s further treatment needs.
	  e.   	 The pharmacist in charge is responsible for maintaining accurate records of dispensing of drugs from the emergency room, and for ensuring the accuracy of prepackaged drugs and the complete and accurate labeling of prepackaged drugs pursuant to subrule 7.12(3).
	  f.   	 Except as provided in subrule 7.12(6), a practitioner who authorizes dispensing to a patient of a prescription drug from the emergency department drug supply is responsible for the accuracy of the dispensed drug and for the accurate completion of label information pursuant to subrule 7.12(4).
	 7.12(3) Prepackaging. Except as provided in subrule 7.12(6), drugs dispensed in greater than a 24-hour supply may be dispensed only in prepackaged quantities not to exceed a 72-hour supply or the minimum prepackaged quantity in suitable containers. Prepackaged drugs shall be prepared pursuant to the requirements of 657—22.3(126). Drugs dispensed pursuant to this subrule shall be appropriately labeled as required in subrule 7.12(4), including necessary auxiliary labels.
	 7.12(4) Labeling. Except as provided in subrule 7.12(6), at the time of delivery of the drug, the practitioner shall appropriately complete the label, such that the dispensing container bears a label with at least the following information:
	  a.   	 Name and address of the hospital;
	  b.   	 Date dispensed;
	  c.   	 Name of prescriber;
	  d.   	 Name of patient;
	  e.   	 Directions for use;
	  f.   	 Name and strength of drug.
	 7.12(5) Delivery of drug to patient. Except as provided in subrule 7.12(6), the practitioner, or a licensed nurse under the supervision of the practitioner, shall give the appropriately labeled, prepackaged drug to the patient or patient’s caregiver. The practitioner, or a licensed nurse under the supervision of the practitioner, shall explain the correct use of the drug and shall explain to the patient that the dispensing is for an emergency or starter supply of the drug. If additional quantities of the drug are required to complete the needed course of treatment, the prescriber shall provide the patient with a prescription for the additional quantities.
	 7.12(6) Use of InstyMeds dispensing system.  A hospital located in an area of the state where 24-hour outpatient pharmacy services are not available within 15 miles of the hospital may implement the InstyMeds dispensing system in the hospital emergency department only as provided by this subrule.
	  a.   	 Access to the dispensing machine for the purposes of stocking, inventory, and monitoring shall be limited to pharmacists, pharmacy technicians, and pharmacist-interns.
	  b.   	 The InstyMeds dispensing system shall be used only in the hospital emergency department for the benefit of patients examined or treated in the emergency department.
	  c.   	 The dispensing machine shall be located in a secure and professionally appropriate environment.
	  d.   	 The stock of drugs maintained and dispensed utilizing the InstyMeds dispensing system shall be limited to acute care drugs provided in appropriate quantities for a 72-hour supply or the minimum commercially available package size, except that antimicrobials may be dispensed in a quantity to provide the full course of therapy.
	  e.   	 Drugs dispensed utilizing the InstyMeds dispensing system shall be appropriately labeled as provided in 657—subrule 6.10(1), paragraphs “a” through “g.”
	  f.   	 Prior to authorizing the dispensing of a drug utilizing the InstyMeds dispensing system, the prescriber shall offer the patient the option of being provided a prescription that may be filled at the pharmacy of the patient’s choice.
	  g.   	 When appropriate for an acute condition, the prescriber shall provide to the patient or the patient’s agent a prescription for the remainder of drug therapy beyond the supply available utilizing the InstyMeds dispensing system. During consultation with the patient or the patient’s agent, the prescriber shall clearly explain the appropriate use of the drug supplied, the need to have a prescription for any additional supply of the drug filled at a pharmacy of the patient’s choice, and the need to complete the full course of drug therapy.
	  h.   	 The pharmacy shall, in conjunction with the hospital emergency department, implement policies and procedures to ensure that a patient utilizing the InstyMeds dispensing system has been positively identified.
	  i.   	 The hospital pharmacist shall review the printout of drugs provided utilizing the InstyMeds dispensing system within 24 hours unless the pharmacy is closed, in which case the printout shall be reviewed during the first day the pharmacy is open following the provision of the drugs. The purpose of the review is to identify any dispensing errors, to determine dosage appropriateness, and to complete a retrospective drug use review of any antimicrobials dispensed in a quantity greater than a 72-hour supply. Any discrepancies found shall be addressed by the pharmacy’s continuous quality improvement program.