The hospital safely manages pharmaceutical services.

(1)

When an on-site pharmacy is not open 24 hours a day, 7 days a week, the following occurs: - A health care professional, who the hospital determines is qualified, reviews the medication order in the pharmacist’s absence - A pharmacist conducts a retrospective review of all medication orders during this period as soon as a pharmacist is available or the pharmacy opens

(2)

When automatic dispensing cabinets are used, the hospital develops and implements a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews. A 100% review of overrides is not required.