Policies and Procedures
General Policies

Pharmacy Scope of Services


Administration of Cancer Chemotherapy

Administration of Hazardous Drugs

Administration of Medications with Dose and Frequency Ranges, Multiple Analgesic Orders

Adult Extravasation Management (Vesicants)

Adverse Drug Event Reporting

Automated Medication Dispensing Cabinet (Omnicell) Procedure

Barcoded Medication Administration

Birth Place Hypertension Policy

CIWA (Clinical Institute Withdrawal Assessment) Protocol

Clostridium Difficile Policy

Compounded Sterile Preparations Standard Operating Policy

Concentrated Electrolytes

Drug Diversion Policy

DKA or HHS Policy

Drug Samples Policy

ED Procedural Sedation

ED To-Go Medications Policy

Formulary Addition Request Form

Formulary: Non-Formulary Drugs

High Alert Medication Policy

HIV Postexposure Prophylaxis

HIV PEP Kit Procedure

Home Medications

ICU Drip Chart

Inspections: Medication Areas (Floor Stock)

Investigational Drugs Policy

IV to PO Conversion Policy

Labeling and Dispensing Policy

Look-Alike / Sound-Alike Drugs

Medication Administration Standards

Medication Administration through Enteral Feeding Tubes

Medication Ordering and Processing Policy

Medication Reconciliation

Medications Sent Home With Patients

Nasal MRSA PCR Protocol

Non-Formulary Request Form

Patient Controlled Analgesia

Pediatric and Adolescent Patients Intravenous Therapy

Peripheral IV Therapy Policy

Pre-Operative Medications

Rabies Exposure Policy

Renal Dosing Program

Restricted Antibiotics List

Restricted ICS Medications

Safe Ordering Practices for Chemotherapy Agents

Self-Administration of Medications

Stop Order Policy For Acute Care Patients

Stop Order Policy For Hospital-Based Skilled Nursing Facility Patients

Titrated Medications

TPN Policy

Transdermal Analgesia for Pediatric Patients

Unacceptable Abbreviations List

Medication Group Policies

Adult Pharmacokinetic Dosing Protocol

AMI with Stent 30 Day Supply of Plavix Workflow

Reversal of Oral Angicoagulants

Anticoagulant Monitoring Guidelines

Anticoagulant Transitions

Beta-Lactam Antibiotic Use in Patients With Reported Allergic Reactions to Beta-Lactam Agents

Controlled Substances

Herbal Supplement Products Policy

Nutritional Products

Retention Enemas: Kayexalate Enema, Milk and Molasses Enema

Treatment of Significant Hyponatremia with Hypertonic Saline

Influenza-Pneumococcal Vaccination Protocol

Respiratory Medications Policy

Long-acting Beta Agonist/Short-acting Beta Agonist Inhalation Medication Policy

Medications Requiring Cardiac and/or Special Monitoring

Restricted Antibiotics List

Corticosteroid Taperpack Policy

Medication Single Policies

Alteplase Infusion for Acute Ischemic Stroke, Myocardial Infarction and Pulmonary Embolus

buprenorphine/methadone Policy

clozapine (Clozaril) Policy

enoxaparin (Lovenox) Policy

fentanyl intra-nasal ED Use For Pediatric Patients Policy

fondaparinux (Arixtra) Monitoring Protocol

Heparin Prophylaxis Monitoring Program

IV Heparin Administration (Anti-Xa based)

IV Immune Globulin Policy

IV Lidocaine in the ED for Acute Pain

Humulin U-500 Insulin Policy

Insulin Pump Policy

Insulin Pump Entry Instructions

Lidocaine Use with IV insertion

Management of Bleeding Events with dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis)

meropenem (Merrem) Policy

metFORMIN in Patients Receiving Iodinated IV Contrast

methadone/buprenorphine Policy

midazolam (Versed)

midazolam intra-nasal ED Use For Pediatric Patients Policy

mitoMYcin Intravesicular

NOWS Morphine Treatment Protocol

IV phenytoin (Dilantin) Policy

piperacillin-tazobactam (Zosyn) Extended Dosing Interval Policy

Potassium Chloride IV Policies

promethazine (Phenergan) IV Policy

tirofiban (Aggrastat) Policy

Vitamin K Route Substitution For Reversal of Warfarin (Coumadin)

Vitamin K guidelines


Pharmacy Contact Info:

Main Inpatient Pharmacy: ext 4599, 3503
Fax: 704-878-7283

Director of Pharmacy - Randi Raynor, PharmD: ext 4501
Clinical Coordinator - Laura Rollings, PharmD: ext 4597
Pharmacy Informaticist - Stephen Pringle, PharmD: ext 7645
Pharmacy Technician Supervisor - Amy Wingler, CPhT: ext 7385
Pharmacy Automation Coordinator (Omnicell) - Melissa Fulford, CPhT: ext 3556



This site is intended for the staff of Iredell Memorial Hospital.
While others may view accessible pages, Iredell Memorial Hospital makes no warranty, express or implied,
as to the use of this information outside of Iredell Memorial Hospital.
The content of this policy and procedure document serves as guidance to the delivery of quality patient care.
Care providers are expected to exercise critical thinking and situational awareness skills,
and in specific situations to take such action as is necessary for the delivery of quality patient care.