In those hospitals not having 24‑hour outpatient pharmacy services or those hospitals having no outpatient pharmacy services, controlled substances dispensed to emergency department patients when the pharmacy service is closed shall follow this procedure:

(1)           All controlled substances shall be dispensed to a bona fide patient, or his agent, of the emergency room pursuant to the written or verbal order of a licensed practitioner who is registered with the Federal Drug Enforcement Administration to prescribe or dispense controlled substances.

(2)           The pharmacist designated by the hospital shall be responsible for developing and supervising a system of control and accountability of all controlled substances administered in or dispensed from the emergency department.

(3)           The hospital's emergency department committee (or like group or person responsible for policy in that department) in conjunction with the hospital pharmacy shall  develop an emergency department formulary or controlled substances list of those controlled substances which may be dispensed from the emergency department for patients receiving care in that department.  This formulary or controlled substances list shall consist of controlled substances of the nature and type to meet the immediate need of emergency department patients, and quantities in each container shall be limited to not more than a 24‑hour supply.

(4)           Such controlled substances shall be prepackaged in suitable safety closure containers and shall be appropriately prelabeled (including necessary auxiliary labels) by the pharmacy so as to provide for all label information necessary for use as well as other information required by law.

(5)           At the time of delivery of the controlled substance, the physician, or physician assistant or a registered nurse under his direction shall appropriately complete the label and initial it.

(6)           A suitable and perpetual record of dispensing of these controlled substances shall be maintained in the emergency department.  The pharmacist shall verify the correctness of this record at least once a week.

(7)           The dispenser shall sign the record of dispensing that is maintained in the emergency department to verify the controlled substance ordered.

(8)           When the controlled substances are delivered, the appropriately labeled, prepackaged container of the controlled substance shall be checked for correctness and given to the patient by the physician or by a person authorized to prescribe or dispense controlled substances pursuant to G.S. 90‑18.1 or by a registered nurse or physician assistant under the supervision of the ordering physician.


History Note:        Authority G.S. 90‑100; 143B‑147(a)(5);

Eff. June 30, 1978;

Amended Eff. May 1, 1990; January 14, 1981; September 15, 1980; September 30, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. February 2, 2016.