Institutional Pharmacy Inspection: Instruction Sheet and Form

Nevada State Board of Pharmacy431 W. Plumb Lane Reno, Nevada 89521(775) 850-1440 (800)-364-2081 Fax (775) 850-1444Institutional Inspection FormDISTRIBUTION OF DRUGSLimitations on distribution of drugs [NAC 639.478]Only upon order of a practitioner or his agent? Yes NAOriginal/direct copy of practitioner’s order? Yes NADoes a written policy regarding automatic stop orders exist? Yes NANON 24 HOUR PHARMACIES ONLY:Withdrawal of drug by non-pharmacist [NRS 639.2324, NAC 639.479,NAC 639.480,NAC 639.481]Quality limited to immediate medical needs? Yes NADesignated licensed nurse/practitioner removed the product? Yes NAProper record maintained? Yes NAPractitioner’s order forwarded to pharmacy? Yes NAPharmacist reconciled balance within 7 days? Yes NAName of Patient? Yes NAName, strength and quantity of drug? Yes NADirections for use? [NRS 639.2353 3., NRS 454.223, NAC 453.015] Yes NAThe date of issue? Yes NAPARENTERAL PREPARATIONS [NAC 639.674-NAC 639.692] [LCB file R035-06]Does the facility provide parenteral preparation services? Yes NADoes the pharmacy prepare cytotoxic agents/hazardous drugs(carcinogenicity/teratogenicity or other development toxicity/reproductivetoxicity/organ toxicity at low doses/genotoicity/compounded drug product)whose structure and/or toxicity profiles mimics an existing drug product thatproduces one or more of the characters noted? Yes NAFill out the Nevada State Board of Pharmacy Institutional/Parenteral Inspectionform addendum if you answered yes to either of the above 2 questions.INVESTIGATIONAL DRUGS [NAC 639.455, NAC 477(b) and NAC 639.468, 13.]Does the pharmacy have an investigational drug system? (if NO skip to P&T) Yes NAAre policies and procedures in place? Yes NADrug protocol on file in pharmacy? Yes NAApproved by Pharmacy and Therapeutics Committee? Date:__________ Yes NADispensing controlled by pharmacy? Yes NANevada State Board of Pharmacy Institutional Inspection Form 1/30/2014 Page 6 of 21