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Subpart 1.

Limited access.

Only a pharmacist may have access to the pharmacy except in the following situations and under the following conditions set forth in subparts 2 and 3.

Subp. 2.


In the case of disaster, the hospital administrator may allow access for purposes of emergency maintenance, disaster prevention and control, and patient safety.

Subp. 3.


For purposes of withdrawing limited doses of drugs for administration to inpatients in emergencies when the pharmacy is closed, a designated registered nurse may make emergency withdrawal of a dose required by a patient. Only a designated registered nurse in any given shift may have emergency access.

The person withdrawing from a bulk stock container the limited doses for administration shall leave in the pharmacy, on a form developed by the pharmacy, a record of the drugs withdrawn showing the patient's name, the name of the drug and dose prescribed, drug strength, the amount taken, the time and date, and the signature of nurse withdrawing drug.

The person withdrawing the drug from a bulk stock container or unit dose packaging bin shall place upon the record of withdrawal the container from which the limited doses were taken so that the withdrawal may be verified by the pharmacist.

Subp. 4.

Emergency access procedure.

The pharmacist-in-charge shall develop an emergency access procedure and may make provisions for prepackaged drugs for emergency withdrawal, provided the number of doses does not exceed the number usually required by a patient during the time the pharmacy is closed.

Statutory Authority:

MS s 151.06


18 SR 1145

Published Electronically:

September 21, 2011

Official Publication of the State of Minnesota
Revisor of Statutes