Quality Management
Operation of a Community Pharmacy
Policies and Procedures
Date last modified by Pharmacy manager
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Table of Contents
Introduction .................................................................................................................................................. 3
Pharmacy Manager Responsibilities ............................................................................................................. 4
Dress Codes and Name Badges ..................................................................................................................... 7
Employee Registrant Information ................................................................................................................. 8
Staff Contact Information and Signature Log ............................................................................................... 8
New Information Accessibility ....................................................................... Error! Bookmark not defined.
Pharmacy Staff Duties .................................................................................... Error! Bookmark not defined.
Inventory Management ................................................................................. Error! Bookmark not defined.
Narcotic Reconciliation .................................................................................. Error! Bookmark not defined.
Product Selection ........................................................................................... Error! Bookmark not defined.
Expired/Unusable Medications...................................................................... Error! Bookmark not defined.
Patient Returned Medications ....................................................................... Error! Bookmark not defined.
Drug Disposal ................................................................................................. Error! Bookmark not defined.
Security and Storage ...................................................................................... Error! Bookmark not defined.
Drug Recalls.................................................................................................... Error! Bookmark not defined.
Confidentiality of Records and Unauthorized Access, Collection, Use, Disclosure, or Disposal of Personal
Information .................................................................................................... Error! Bookmark not defined.
Premises Security ........................................................................................... Error! Bookmark not defined.
Licensed Operating Name .............................................................................. Error! Bookmark not defined.
Internet Services ............................................................................................ Error! Bookmark not defined.
Emergency Preparedness Plan....................................................................... Error! Bookmark not defined.
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Introduction
The BCPhA has developed Policy and Procedure Manuals to support pharmacies in
documenting policy and procedures that ensure operational activities are compliant with the
regulatory framework governing pharmacy practice.
Each section includes open field description boxes to be completed with your practice’s
policies/procedures or checkboxes meant to act as an acknowledgement that the statement
that follows applies to your practice.
Description fields and check boxes are marked in grey so that they are easily identified.
Description fields are simple to use, just click and type into the space. Checkboxes require a
double-click followed by selecting “Checked”.
You may choose to print this booklet out upon completion to have a copy available for your
staff that need to refer to this guide while keeping the electronic copy saved when updates
need to be applied.
BCPhA has no objection if you add your organization’s logo or otherwise customize the
template. If you do so, please retain the footer crediting BCPhA.
BCPhA has made its best effort to develop this template to assist members.
The user is solely responsible for its obligations.
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Pharmacy Manager Responsibilities
PODSA Bylaw 3 2(a to z)
A manager must do all of the following:
a) actively participate in the day-to-day management of the pharmacy;
b) confirm that the staff members who represent themselves as registrants are registrants;
See: Employee Registrant Information
c) notify the registrar in writing of the appointments and resignations of registrants as they
occur;
See: Employee Registrant Information
d) cooperate with inspectors acting under section 17 of the Act or sections 28 or 29 of the
Health Professions Act;
e) ensure that registrant and pharmacy assistant staff levels are commensurate with the
workload volume and patient care requirements at all times;
f) ensure that new information directed to the pharmacy pertaining to drugs, devices and
drug diversion is be immediately accessible to registrants and pharmacy assistants;
See: New Information Accessibility
g) establish policies and procedures to specify the duties to be performed by registrants
and pharmacy assistants;
See: Pharmacy Staff Duties,
See Pharmacist Refusal to Provide PPP-35
h) establish procedures for

inventory management,
See: Inventory Management
See: Narcotic Reconciliation

product selection, and
See: Product Selection

proper destruction of unusable drugs and devices;
See: Destruction of Unusable Drugs and Devices
See: Expired / Returned Medications
See: Patient Returned Medications
See: Disposal of Medications
i) ensure that all records related to the purchase and receipt of controlled drug substances
are signed by a full pharmacist;
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j) ensure appropriate security and storage of all Schedule I, II, and III drugs and controlled
drug substances for all aspects of pharmacy practice including operation of the
pharmacy without a registrant present;
See: Security and Storage
k) ensure there is a written drug recall procedure in place for pharmacy inventory;
See: Drug Recalls,
See: Automated Pharmacy Dispensing System PPP-43
l) ensure that all steps in the drug recall are documented, if the procedure is initiated;
See: Drug Recalls
m) ensure that each individual working in the pharmacy wears a badge that clearly
identifies the individual’s registrant class or other status;
See: Dress Codes and Name Badges
n) ensure that confidentiality is maintained with respect to all pharmacy and patient
records in accordance with all applicable legislation;
See: Confidentiality of Records
o) make reasonable security arrangements in respect of unauthorized access, collection,
use, disclosure or disposal of personal information kept on the pharmacy premises;
See: Unauthorized Access, Collection, Use, Disclosure or Disposal of
Personal Information
See: Duration of Record Keeping
See: Destruction of Records, See: Confidentiality Undertakings
p) notify the registrar as soon as possible in the event that he or she will be absent from
the pharmacy for more than eight weeks;
q) notify the registrar in writing within 48 hours of ceasing to be the pharmacy’s manager;
r) ensure the correct and consistent use of the community pharmacy operating name as it
appears on the community pharmacy license for all pharmacy identification on or in
labels, directory listings, signage, packaging, advertising and stationery;
See: Licensed Operating Name
s) ensure that appropriate security is in place for the premises generally;
See: Premises Security
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t) in the event of a pharmacy closure or relocation,
i. notify the registrar in writing at least thirty days before the effective date of a
proposed closure or relocation, unless the registrar determines there are
extenuating circumstances,
ii. provide for the safe transfer and appropriate storage of all Schedule I, II, and III
drugs and controlled drug substances,
iii. advise the registrar in writing of the disposition of all drugs and prescription
records at the time of a closure,
iv. provide the registrar with a copy of the return invoice and any other
documentation sent to Health Canada in respect of the destruction of all
controlled drug substances,
v. arrange for the safe transfer and continuing availability of the prescription
records at another pharmacy, or an off-site storage facility that is secure, and
vi. remove all signs and advertisements from the closed pharmacy premises;
u) Ensure sample medications are dispensed in accordance with the requirements in the
Drug Schedules Regulation;
See: Sample Medications
v) advise the registrar if the pharmacy is providing pharmacy services over the internet,
and provide to the registrar the internet address of every website operated or used by
the pharmacy;
See: Internet Services
w) ensure the pharmacy contains the reference material and equipment approved by the
board from time to time
x) require all registrants, owners, managers, directors, pharmaceutical representatives,
pharmacy assistants and computer software programmers or technicians who will
access the in-pharmacy computer system to sign an undertaking in a form approved by
the registrar to maintain the confidentiality of patient record information;
y) retain the undertakings referred to in paragraph (x) in the pharmacy for 3 years after
employment or any contract for services has ended;
z) be informed of the emergency preparedness plan in the area of the pharmacy that he or
she manages and be aware of his or her responsibilities in conjunction with that plan.
See: Emergency Preparedness Plan
See: Pharmacy Disaster Preparedness PPP- 2
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Dress Codes and Name Badges
Policy
The pharmacy manager is responsible for establishing dress codes for all pharmacy staff and for
ensuring that each individual working in the pharmacy wears a badge that clearly identifies the
individual’s registrant class or other status.
Purpose
To ensure that all pharmacy staff are aware of the dress code expectations and that they have
name badges that identify their registrant class or other status.
Applicability
Applies to all pharmacy staff.
References
Pharmacy Manager Responsibilities
PODSA Bylaw 3, 2(m)
Implementation Procedures
Dress Code
Each person working in the pharmacy must wear a badge that clearly identifies the
individual’s role (requirement).
Describe your uniform or attire expectations:
Describe your pharmacist attire expectations
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Employee Registrant Information
Policy
The pharmacy manager is responsible for confirming that all staff members who represent
themselves are registrants and the manager must notify the registrar in writing of the
appointments and resignations of registrants as they occur.
Purpose
To ensure that all registrant staff in the pharmacy are correctly registered and that the
Registrar is aware of the place of employment for each registrant.
Applicability
Applies to all registrants (pharmacists and pharmacy technicians).
References
Pharmacy Manager Responsibilities
PODSA Bylaw 3, 2(b, c)
Implementation Procedures
When hiring/terminating employees the pharmacy manager:
Checks with the College to confirm that each registrant staff member is registered and
in good standing at the time of initiating employment.
Notifies the Registrar at the time of hiring a registrant.
Notifies the Registrar at the termination of employment of a registrant.
The pharmacy manager maintains a record of the name, registrant status, contact
information, and registration number of each registrant. This information can be
incorporated into a signature log so that the registrant‘s initials and signature are
identifiable in the future.
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