Practice Topics > Hospital Pharmacy Accreditation and Operation Practice Topic
PRACTICE TOPIC

Hospital Pharmacy Accreditation and Operation Practice Topic

Hospitals are subject to oversight from several system partners and have accountabilities under multiple pieces of legislation. The Drug and Pharmacies Regulation Act provides the College with the authority to accredit and inspect pharmacies within public and private hospitals. For these purposes, any location in a hospital where drugs are stored, compounded, dispensed, supplied from or for hospital inpatients or outpatients patients is deemed to be a pharmacy.

STANDARDS, POLICIES AND GUIDANCE

COLLEGE RESOURCES

FAQs

  • Registrants must only engage in restocking of drugs under the authority of the accredited hospital pharmacy where the pharmacy has established this practice as permitted through the DPRA, O. Reg. 264/16, s.20.

    With respect to the integrity of the drug, it is the College’s expectation that the accredited hospital pharmacy ensures that the drug has been in the possession of a licensed healthcare professional at all times (from time of dispensing to time of return to the pharmacy). If the drug has left the possession of a licensed healthcare professional, even for a short period of time, the drug integrity cannot be verified and restocking is not permitted. The licensed healthcare professional who has been in possession of the drug should confirm that the drug has been stored in accordance with the manufacturer’s requirements (e.g. appropriate temperature, etc.).

  • The College collaborated with the North East LHIN ’s Hospital Pharmacy Peer Group to develop an integrated strategy for hospital pharmacy medication management services as a region. The North East LHIN Regional Pharmacy Strategy was published on July 2018 and provides a framework to guide LHINs and hospitals to work together to make regional decisions that will ensure hospitals, as a region, collectively provide medication management services according to standards. The strategy acknowledges the importance of broader medication management practices but focuses on sterile compounding and prioritizes patient safety through the critical elements, patient access to services and optimizing volume of service delivery as a region. LHINs and hospitals may choose to use this framework to inform a coordinated regional approach to capital funding requests that accurately reflect the needs of the region. If LHINs and hospitals determine that there is a need for capital investments after going through the process outlined in the strategy, a LHIN-coordinated submission to the Ministry of Health for funding is recommended. 
     
    (LHIN = Local Health Integration Network. As of April 2021, Ontario’s LHINs have transitioned to Ontario Health as Home and Community Care Support Services)

EXTERNAL RESOURCES

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