DEPARTMENT     POLICY                      POLICY                     RESCINDED       RELATED       REVIEWED/      EFFECTIVE      NEXT REVIEW          STATUS
                   UNIT         NO.                        TITLE                     POLICY(IES)   POLICY(IES)      REVISED          DATE            DATE
             Pharmacy                                Certification Sheet 
             Pharmacy           101    Purpose of Policy and Procedure Manual                                      03/23/2018      12/1/1994      03/23/2021
             Pharmacy           201    Mission Statement                                                           03/23/2018      12/1/1994      03/23/2021
             Pharmacy           202    Integration of Pharmacy Services into the                                   03/23/2018      6/1/2007       03/23/2021
                                       Hospital Organization
             Pharmacy           203    Pharmacy Organization Plan                                                  03/23/2018      2/1/1995       03/23/2021
             Pharmacy           301    Scope of Service                                                            03/23/2018      2/1/1995       03/23/2021
             Pharmacy           302    Pharmacy Staffing                                                           03/23/2018      2/1/1995       03/23/2021
             Pharmacy           303    Certification of Funds: Pharmacy Stock                                      03/23/2018      2/1/1995       03/23/2021
                                       Inventory Requisitions
             Pharmacy           304    Patient Confidentiality and Data Security                                   03/23/2018      5/1/2006       03/23/2021
             Pharmacy           305    Pharmacy Staff Confidentiality Attestation                                  03/23/2018      5/1/2006       03/23/2021
             Pharmacy           306    Pharmacy Key Control                                                        03/23/2018      2/1/1995       03/23/2021
             Pharmacy           307    Orientation: Pharmacy Personnel                                             03/23/2018      2/1/1995       03/23/2021
             Pharmacy           308    Committee Membership                                                        03/23/2018      2/1/1995       03/23/2021
             Pharmacy           309    Poison Control and Antidotes                                                03/23/2018      2/1/1995       03/23/2021
             Pharmacy           310    Infection Control in the Pharmacy                                           03/23/2018      2/1/1995       03/23/2021
             Pharmacy           312    Break Periods                                                               03/23/2018      2/1/1995       03/23/2021
             Pharmacy           313    Dress and Grooming Codes                                                    03/23/2018      2/1/1995       03/23/2021
             Pharmacy           314    Pharmacy Staff Meeting                                                      03/23/2018      2/1/1995       03/23/2021
             Pharmacy           315    Continuing Education for Pharmacy Staff                                     03/23/2018      2/1/1995       03/23/2021
             Pharmacy           317    Staff Emails                                                                03/23/2018      02/26/14       03/23/2021
             Pharmacy           401    Job Descriptions                                                            03/23/2018      2/1/1995       03/23/2021
             Pharmacy           402    Absenteeism                                                                 03/23/2018      2/1/1995       03/23/2021
             Pharmacy           403    Pharmacy Licenses and Registrations                                         03/23/2018      2/1/1995       03/23/2021
             Pharmacy           501    Pharmacy and Therapeutics Committee                                         03/23/2018      5/1/1989       03/23/2021
               DEPARTMENT     POLICY                      POLICY                     RESCINDED       RELATED       REVIEWED/      EFFECTIVE      NEXT REVIEW          STATUS
                   UNIT         NO.                        TITLE                     POLICY(IES)   POLICY(IES)      REVISED          DATE            DATE
             Pharmacy           502    Drug Formulary                                                              03/23/2018      8/4/1999       03/23/2021
             Pharmacy           503    Generic Substitution                                                        03/23/2018      12/1/1994      03/23/2021
             Pharmacy           504    Investigation Drugs                                                         03/23/2018      12/1/1994      03/23/2021
             Pharmacy           505    Sample Drugs                                                                03/23/2018      12/1/1994      03/23/2021
             Pharmacy           601    Procurement of Drugs                                                        03/23/2018      6/1/2007       03/23/2021
             Pharmacy           602    Pharmacy Inventory Control                                                  03/23/2018      2/1/1995       03/23/2021
             Pharmacy           605    Loan and Borrow of Pharmaceuticals                                          03/23/2018      3/25/1995      03/23/2021
             Pharmacy           606    Detecting of Deteriorating Drug                                             03/23/2018      6/1/1997       03/23/2021
             Pharmacy           607    Disposition of Expired Drugs                                                03/23/2018      9/1/1989       03/23/2021
             Pharmacy           608    Drug Return Policy                                                          03/23/2018      2/1/1995       03/23/2021
             Pharmacy           609    Drug Recall                                                                 03/23/2018      12/1/1994      03/23/2021
             Pharmacy           610    Storage and Security of Drugs                                               03/23/2018      2/1/1995       03/23/2021
             Pharmacy           611    Refrigeration of Drugs                                                      03/23/2018      2/1/1995       03/23/2021
             Pharmacy           612    Blood Derivatives-Albumin                                                   03/23/2018      2/1/1995       03/23/2021
             Pharmacy           613    Concentrated Intravenous Electrolytes                                       03/23/2018      2/1/1995       03/23/2021
             Pharmacy           614    Radioactive Medications and Contrast Media                                  03/23/2018      2/1/1995       03/23/2021
             Pharmacy           615    Radioactive Materials-Ordering, Receiving, and                              03/23/2018      6/1/2007       03/23/2021
                                       Handling
                                                                                                                                  11/27/19         11/22
             Pharmacy           616    Automated Dispensing Machines - Inspection                                  03/23/2018     10/23/2017      03/23/2021
                                                                                                                   1/22/20
                                       And Inventory
             Pharmacy           701    Medication Orders                                                           03/23/2018      2/1/1995       03/23/2021
             Pharmacy           702    Metric System                                                               03/23/2018      1/1/1995       03/23/2021
             Pharmacy           703    High Risk/High Alert Medication                                             03/23/2018      6/4/2007       03/23/2021
             Pharmacy           704    Look-Alike/Sound-Alike Medications                                          03/23/2018      6/4/2007       03/23/2021
             Pharmacy           705    In-Patient Dispensing                                                       03/23/2018      2/1/1995       03/23/2021
               DEPARTMENT     POLICY                     POLICY                     RESCINDED       RELATED       REVIEWED/      EFFECTIVE      NEXT REVIEW         STATUS
                   UNIT         NO.                       TITLE                     POLICY(IES)   POLICY(IES)      REVISED         DATE             DATE
             Pharmacy           706    Review, Verification, Interpretation of                                    03/23/2018      1/1/1995       03/23/2021
                                       Medication Orders
             Pharmacy           707    Patient's Profile                                                          03/23/2018     6/30/2007       03/23/2021
             Pharmacy           708    Labeling Standard for Medications                                          03/23/2018     9/23/2005       03/23/2021
             Pharmacy           709    Unit Dose Policy                                                           03/23/2018      5/1/1989       03/23/2021
             Pharmacy           710    Pharmacy Compounding Policy                                                03/23/2018     6/30/2007       03/23/2021
             Pharmacy           711    Off-Island Medications                                                     03/23/2018      2/1/1995       03/23/2021
             Pharmacy           713    Medication Administration                                                  03/23/2018      2/1/1995       03/23/2021
             Pharmacy           714    Uniform Drug Administration Schedule                                       03/23/2018      2/1/1995       03/23/2021
             Pharmacy           715    Automatic Medication Stop Order                                            03/23/2018      2/1/1995       03/23/2021
             Pharmacy           716    Patient's Own Medication                                                   03/23/2018      3/1/2003       03/23/2021
             Pharmacy           717    In-Patient Self-Administration of Medication                               03/23/2018      2/1/1995       03/23/2021
             Pharmacy           718    Bedside Storage of Medication                                              03/23/2018      6/1/2007       03/23/2021
             Pharmacy           720    Pharmacy Repackaging of Unit Dose and Unit                                 03/23/2018      6/1/2007       03/23/2021
                                       Dose
             Pharmacy           721    Decreasing Medication Errors                                               03/23/2018      6/1/2007       03/23/2021
             Pharmacy           722    Pediatric Dosing                                                           03/23/2018      6/1/2007       03/23/2021
             Pharmacy           723    Enhancing Pharmaceutical Services at Skilled                               03/23/2018     6/10/2008       03/23/2021
                                       Nursing Unit
             Pharmacy           724    Monitoring Effects of New Medications on                                   03/23/2018     2/10/2012       03/23/2021
                                       Patients
             Pharmacy           725    Beyond Use Dating - Oral Solutions                                         03/23/2018     01/21/2016      03/23/2021
             Pharmacy           726    Titrating/Tapering Of Medications                                          03/23/2018     10/23/2017      03/23/2021
             Pharmacy           727    Medication Administration Record Document                                  03/23/2018     10/23/2017      03/23/2021
             Pharmacy           728    Psychotropic Medications                                                   03/23/2018     10/23/2017      03/23/2021
             Pharmacy           729    Beyond Use Dating - Topical Irrigation Solutions                            5/3/2018      5/16/2018         5/2021
             Pharmacy           730    Medication Reconciliation                                                  01/22/2020     01/22/2020      01/22/2023
             Pharmacy           801    Policy Statement on the Compounding of Sterile                             03/23/2018     8/23/2006       03/23/2021
                                       Parenteral Admixtures
               DEPARTMENT     POLICY                      POLICY                     RESCINDED       RELATED       REVIEWED/      EFFECTIVE      NEXT REVIEW          STATUS
                   UNIT         NO.                        TITLE                     POLICY(IES)   POLICY(IES)      REVISED          DATE            DATE
             Pharmacy           802    Parenteral Admixtures- Ordering and Handling                                03/23/2018      8/23/2006      03/23/2021
             Pharmacy           803    Aseptic Technique-Preparing for Mixing IV                                   03/23/2018      6/1/2007       03/23/2021
                                       Admixture
             Pharmacy           804    Aseptic Technique- Syringe Manipulation                                     03/23/2018      6/1/2007       03/23/2021
             Pharmacy           805    Aseptic Techniques-Reconstitution and Transfer                              03/23/2018      2/1/1995       03/23/2021
                                       of a Drug to a Parenteral Solution
             Pharmacy           806    Discontinued IV Solutions                                                   03/23/2018      6/30/2007      03/23/2021
             Pharmacy           807    Laminar Air-Flow Hood and Biologic Safety                                   03/23/2018      8/23/2006      03/23/2021
                                       Cabinet
             Pharmacy           808    USP 797 Compliance Policy                                                   03/23/2018     06/04/2014      03/23/2021
             Pharmacy           809    Cytotoxic Drugs-Handling/Ordering/Preparing                                 03/23/2018      3/26/2005      03/23/2021
             Pharmacy           810    Cytotoxic Drugs Storage                                                     03/23/2018      6/5/2007       03/23/2021
             Pharmacy           811    Disposal of Cytotoxic Waste                                                 03/23/2018      6/5/2007       03/23/2021
             Pharmacy           812    Cytotoxic Drug Spillage Handling                                            03/23/2018      6/5/2007       03/23/2021
             Pharmacy           813    Total Parenteral Nutrition-TPN & PPN                                        03/23/2018      6/5/2007       03/23/2021
             Pharmacy           814    Handling of Multi-Dose Vial of Injectable Drugs                             03/23/2018      6/4/2007       03/23/2021
             Pharmacy           815    Immediate use of IV Prepared by Nurse in                                    03/23/2018      8/4/1999       03/23/2021
                                       Nursing Units
             Pharmacy           816    Extravasation of Drugs and Antidotes                                        03/23/2018     12/31/1994      03/23/2021
             Pharmacy           901    Controlled Substances General Policy                                        03/23/2018      1/31/1995      03/23/2021
             Pharmacy           902    Registration for Controlled Substances                                      03/23/2018      1/31/1995      03/23/2021
             Pharmacy           903    Controlled Substances: Inpatient Dispensing                                 03/23/2018      1/31/1995      03/23/2021
             Pharmacy           904    Controlled Substances: Outpatient Dispensing                                03/23/2018      1/31/1995      03/23/2021
             Pharmacy           905    Controlled Substances-DEA & CSR Licensure                                   06/08/2007      5/16/2018        5/2021
             Pharmacy           906    Controlled Substances- Verification of                                      03/23/2018      6/8/2007       03/23/2021
                                       Administration Record Entries