13.1 Institutional Practice: Hospitals, Pharmaceutical Administration Facilities & Emergency Drug Kits
Key Takeaways
A hospital controlled substance order for an inpatient or outpatient is exempt from Utah's prescription requirements if the prescriber signs to affirm it in the patient's record within 48 hours (Utah Code § 58-37-304(7)).
A Utah ED prescriber may give up to a three-day emergency supply, a seven-day supply of STI prophylaxis, or a naloxone kit (R156-17b-610.5).
A Utah hospital pharmacy may dispense up to a 72-hour supply to a patient discharged that day when the patient's usual Class A pharmacy is closed or cannot dispense (Utah Code § 58-17b-610.6).
In a Utah pharmaceutical administration facility, a verbal order must be signed by the prescriber within 72 hours for a Schedule II drug and within 30 days for any other prescription drug (R156-17b-614c(3)).
A Utah emergency drug kit stays the property of the supplying pharmacy, must be locked and stored in a locked area, and may be accessed only by the facility's licensed physicians, PAs, and nurses (R156-17b-614c(5)).
13.1 Institutional Practice: Hospitals, Pharmaceutical Administration Facilities & Emergency Drug Kits
Institutional practice appears throughout the blueprint (administration, dispensing exceptions, and practice-setting requirements). In Utah most institutional pharmacies are Class B (Section 1.3).
Hospital controlled substance orders (§ 58-37-304(7))
An order for a Schedule II–V controlled substance for a hospital inpatient or outpatient is exempt from the prescription requirements of § 58-37-304 if:
- the prescriber holds an unrestricted DEA registration and an active Utah controlled substance license (or is a medical resident exempt from licensure);
- the treating prescriber authorizes the order and designates the quantity;
- the order is entered in the patient's record, the prescriber signs to affirm it within 48 hours of filling or administering, and the record shows the quantity actually administered; and
- it is filled by a pharmacist inside the hospital, or taken from a lawful hospital supply and administered directly to the patient.
The prescriber-information elements of § 58-17b-602(1)(a) also don't apply to inpatient orders written by hospital staff and kept in the medical record (§ 58-17b-602(2)).
Dispensing at transitions of care
| Setting | Rule |
|---|---|
| Emergency department (R156-17b-610.5) | The prescriber may provide up to a three-day emergency supply, a seven-day supply of STI prophylaxis, or a naloxone kit. Labels show the prescriber's and facility's name and phone, patient, drug and strength, date, directions, and beyond-use date. Controlled-substance records go to the appropriate pharmacy for CSD reporting. |
| Hospital discharge (§ 58-17b-610.6; R156-17b-610.6) | A hospital pharmacy may dispense up to a 72-hour supply to a person discharged that day if dispensing is needed for the patient's immediate needs, the patient's usual Class A pharmacy is closed or can't dispense, and hospital protocols are followed. During pharmacy hours a pharmacist dispenses; after hours the prescriber may dispense a prepackaged, labeled drug. Opioid antagonists may be dispensed without the Class A condition, and the hospital must accept wholesale acquisition cost. Report controlled substances to the CSD. |
| Discharge in a multidose container (§ 58-17b-602(6)) | A drug used during the stay may go home with the patient, labeled with name, drug and strength, directions, and pharmacy name and phone |
| Methadone for withdrawal (§ 58-37-307) | A hospital practitioner may issue an emergency medical order for up to a 72-hour methadone supply through the hospital's Class A or B pharmacy while arranging treatment referral |
Pharmaceutical administration facilities (R156-17b-614c)
A pharmaceutical administration facility is a facility or agency where drugs are held for administration to its patients. The drugs are dispensed to it by a pharmacist with whom it has a supervising relationship, and staff administer them under practitioners' orders (§ 58-17b-102(44)). It is a Class B pharmacy that does not require a PIC (R156-17b-302(2)). Instead:
- A consulting pharmacist advises on every aspect of pharmacy services, sets up records of controlled-substance receipt and disposition detailed enough for accurate reconciliation, and makes sure drug records are in order and controlled substances are accounted for and periodically reconciled.
- Destruction of drugs is witnessed by the medical or nursing director (or a designated physician, RN, or other licensed employee) and the consulting pharmacist or a licensed technician, following 21 CFR Part 1317.
- Verbal orders from a prescriber may be entered as the prescriber's order. The prescriber must sign within 72 hours for a Schedule II controlled substance and within 30 days for any other prescription drug. The order may be copied and sent to a pharmacy as its prescription record.
Emergency drug kits (R156-17b-614c(5))
| Requirement | Detail |
|---|---|
| Ownership | The kit is a physical extension of the supplying pharmacy and remains its property |
| Contents | Set by the facility's medical director or director of nursing together with the supplying pharmacy's consulting pharmacist. The approved list is posted conspicuously on or near the kit. |
| Use | Only for bona fide emergencies, when medications can't be obtained from a pharmacy in time |
| Records | Both the facility and the pharmacy keep records of receipt and removal |
| Security | Stored in a locked area and locked itself. Accessible only to licensed physicians, PAs, and nurses employed by the facility. |
| Inspection | Open to DOPL and the Department of Health and Human Services |
Other institutional rules
- Counseling is not required for hospital or institutional patients whose drugs are administered by other licensed professionals (R156-17b-610(7)).
- Labels for drugs a provider administers in a pharmaceutical administration facility or hospital are exempt from most outpatient label elements (§ 58-17b-602(5)(b)).
- Tech-check-tech: in a Class B hospital pharmacy, a technician with at least one year of experience and six months at that hospital may check certain medications another technician prepared (ADC fills, cart fills, crash-cart trays, unit dosing), using supporting technology, documented training and competency, an error-reporting system, and an immediately available supervising pharmacist (R156-17b-601(1)(m)). Failing to follow the hospital's technician-checking policies is unprofessional conduct (R156-17b-502(17)).
- CSD: drugs dispensed for administration to patients at a health care facility, including in its outpatient settings, are not reported to the CSD (§ 58-37f-203(3)(b)).
- Opioid treatment programs: a narcotic treatment program pharmacy is Class B and does not require a PIC. Under § 58-17b-309.7, an APRN, RN, or PA ("covered provider") may dispense opioid use disorder medication at an OTP under the direction of a pharmacist (general supervision). The provider may not further delegate. OTP mobile units operate under the OTP's license, may not keep medication on board when not operating, and require notice to DOPL at least one business day before starting or stopping.
A hospitalist verbally orders IV morphine for an inpatient, and a nurse administers it from the automated dispensing cabinet. Under Utah Code § 58-37-304(7), what makes this order exempt from the usual prescription requirements?
The order is exempt only if a pharmacist writes a separate outpatient prescription
The nurse must sign the order within 7 days
The prescriber has an unrestricted DEA registration and Utah CS license, designates the quantity, and signs to affirm the order in the patient's record within 48 hours
Hospital orders are never exempt, so a signed paper prescription is always required
At 11:30 PM, a patient is discharged from a Utah hospital with a new antibiotic prescription, and the patient's usual Class A pharmacy is closed. What may the hospital provide under Utah Code § 58-17b-610.6?
Up to a 72-hour supply dispensed under hospital protocol, by the prescriber from prepackaged labeled stock when the hospital pharmacy is closed
Nothing, because hospitals may never dispense to discharged patients
A 30-day supply, because the patient cannot reach a pharmacy
A 7-day supply, but only if a pharmacist personally dispenses it
A nurse in a Utah pharmaceutical administration facility takes a verbal order from a physician for oxycodone (Schedule II). By when must the physician sign the order in the facility record under R156-17b-614c(3)?
Within 24 hours
Within 7 days
Within 30 days
Within 72 hours
Which statement about an emergency drug kit supplied by a pharmacy to a Utah pharmaceutical administration facility is correct?
The kit may be used routinely whenever a patient's medication is late
The kit remains the supplying pharmacy's property, must be locked and kept in a locked area, and may be accessed only by the facility's licensed physicians, PAs, and nurses
Any facility employee may open the kit during an emergency
The kit becomes the facility's property once delivered
Sections you finish are checked off in the contents.