POLICY:

The Pharmacy Department maintains a constant patient care standard throughout the Hospital. The
following is a list of standard references use by the Department of Pharmacy to guide professional
practice and to assure that medications provided by the pharmacy meet national standards of quality.

I. REFERENCE SOURCES USED AS STANDARDS BY THE PHARMACY
Unless otherwise indicated, each of these references will be maintained in each of the pharmacy
dispensing areas either electronically or as hard copy. Each Assistant Pharmacy Director is
responsible for assuring that the standards and/or policies described in these references are
followed.

A. JHH pharmacy policy and procedure manual
A current version of the Pharmacy Policies and Procedure Manual is available on the
Pharmacy Intranet. The Assistant Director of Regulatory and Legal Affairs maintains the
original copy of this manual with approval signatures.
B. Maryland Pharmacy Act, Board Of Pharmacy Regulations, Drug-Related Statutes
Regulations, Pharmacy And Laws & Regulations For The State Of Maryland
The Assistant Director of Regulatory Affairs keeps a current copy of this manual.
Information from this manual is made available to pharmacy staff as appropriate.

C. Comprehensive Accreditation Manual for Hospitals: The Official Handbook

D. JHH Hospital & Medical Staff Bylaws, Rules, & Regulations
Available at http://jhmcis.jhmi.edu/cvo/Bylaws.htm

E. Sterile Products Procedure Manual
The Assistant Director of Operations keeps a current copy of this reference. Information
from this manual is made available to pharmacy staff as appropriate.

F. The Johns Hopkins Hospital Drug Formulary

G. List Of Prescriber Codes And DEA Numbers For JHH Authorized Prescribers
A list of DEA numbers for JHH authorized prescribers as well as a list of prescriber
identification code numbers is available in all pharmacy satellites.

H. JHH Human Resources Policy Manual
A current copy of this manual can be found at http://www.med.jhu.edu/jhhr/.

I. Safety & Emergency Procedure Manual JHH
A current copy of this manual can be found at
http://infonet.welch.jhu.edu/research/safety/safetypolicy/

J. JHH Infection Control Manual
A current copy of this manual is kept by pharmacy administration central pharmacy
administration.

K. General Information Texts To Be Kept In Each Dispensing Area
1. American hospital formulary service
2. Hanstens drug interactions
3. Facts and comparisons
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4. Trissels handbook on injectable drugs
5. Micromedex is available on public workstations in the satellite pharmacies.

L. JHH Corporate and Administrative Policies and Procedures
http://infonet.welch.jhu.edu/jhu_only/hos_policy_on_policy/nav.html

II. Drug Standards
All drugs, chemicals and biologicals dispensed by the pharmacy must meet national standards of
quality using criteria established by organizations such as the U.S. pharmacopeia, national
formulary, ASHP, or the FDA. Exceptions may be made for bona fide clinical investigation
when approved by the Pharmacy & Therapeutics Committee and the Joint Committee of Clinical
Investigation.

Approval:

_________________________________ ___________________
Daniel M. Ashby, M.S., FASHP Date
Director, Department of Pharmacy
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