Rules and Regulations 2013 - North Florida Regional Medical Center

North Florida Regional Medical Center
Rules And Regulations
prescriber and new orders written.
In the case of irreversible illness of a patient in which death is imminent where
emergency procedures to treat cardiac or pulmonary arrest may not be desired, the
physician, after appropriate consultation with the patient and/or family and after
adequate documentation in the chart, shall write the order "Do Not Resuscitate".
Specific guidelines for this order are contained within the appropriate Hospital
policies and procedures.
D.5.
Medication Orders - All drugs and medications administered to patients shall be
those listed in the latest edition of: NFRMC Formulary, United States
Pharmacopoeia, National Formulary, and American Hospital Formulary Service.
Drugs of bonafide clinical investigations may be exceptions. These shall be used
in full accordance with the Statement of Principle involved in the use of
Investigational Drugs in Hospitals and all regulations of the Federal Food and
Drug Administration.
The physician or Allied Health Professional must write a complete medication
order consisting of drug name, dosage, route and frequency. Orders which do not
contain all these elements cannot be carried out until completed by the physician
or Allied Health Professional. (6/27/11)
Orders for controlled substances must include a hospital issued unique
identification number or legibly printed name along with the physician or Allied
Health Professional signature. All Allied Health Professionals must write legibly
the name of the specific supervising physician as well as the name of the Allied
Health Professional at the time the order is written. (6/27/11)
Pharmacy and Therapeutics:
develops and maintains surveillance over medication safety, utilization
policies and practices including establishing systems and education
programs to prevent medication errors;
monitors all reported drug reactions and drug errors in order to define
system failures; and
provides a quarterly report, consisting of statistical data involving drug
reactions and drug errors, their probable causes and actions taken to
improve systems and follow-up evaluation to assure the process
improvement is maintained.
D.6.
Medication Administration - Certain medications may be administered only by a
physician or under his/her direct supervision when given by the I.V. push method.
These medications include those in which no FDA approval is available.
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