(1) In an institutional facility that does not have an in-house pharmacy, drugs may be provided for use by authorized personnel through emergency kits prepared by the registered pharmacist providing pharmaceutical services to the facility. Such emergency drug kits must meet all of the following requirements:

(a) a registered pharmacist shall prepare and seal the kit;

(b) the supplying pharmacist and the designated practitioner or appropriate committee of the institutional facility shall jointly determine the identity and quantity of drugs to be included in the kit;

(c) the kit must be locked and stored in a secure area to prevent unauthorized access and to ensure a proper storage environment for the drugs contained therein;

(d) all drugs in the kit must be properly labeled, including lot number and expiration date, and shall possess any additional information that may be required to prevent risk of harm to the patient;

(e) the exterior of the kit must be clearly labeled to indicate:

(i) its use and expiration date of its contents;

(ii) the name, address and telephone number of the supplying pharmacist; and

(iii) a statement indicating that the kit is to be used in emergency situations only pursuant to a valid drug order.

(2) Drugs shall be removed from emergency kits only by the supplying pharmacist or by authorized personnel pursuant to a valid drug order.

(3) The supplying pharmacist shall be notified of any entry into the kit. The supplying pharmacist shall have a mechanism defined in policy to restock and reseal the kit within a reasonable time so as to prevent risk of harm to patients.

(4) The expiration date of a kit must be the earliest date of expiration of any drug supplied in the kit. On or before the expiration date, the supplying pharmacist shall replace the expired drug.

(5) The supplying pharmacist shall, in conjunction with the appropriate institutional committee, be responsible for development of policies and procedures for safe and appropriate use and maintenance of emergency drug kits.