Skip to main content
Back To Top Top Back To Top
This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 4729:5-6 | Nuclear Pharmacies

 
 
 
Rule
Rule 4729:5-6-01 | Definitions - nuclear pharmacies and radiopharmaceuticals.
 

As used in Chapter 4729:5-6 of the Administrative Code:

(A) "Radiopharmaceutical," "radiopharmaceutical preparation," or "radioactive drug" means a finished dosage form of a dangerous drug that contains a radioactive substance in association with one or more other ingredients and that is intended to diagnose, stage a disease, monitor treatment, or provide therapy. A radiopharmaceutical includes any nonradioactive reagent kit or radionuclide generator that is intended to be used in the preparation of any such substance. The terms "radiopharmaceutical" and "radioactive drug" are commonly used interchangeably.

(B) "Authorized nuclear pharmacist" means a licensed pharmacist that meets the requirements in rule 3701:1-58-20 of the Administrative Code.

(C) "Beyond-use date" means the assigned date and time beyond which the radiopharmaceutical must not be administered.

(D) "Compounding" has the same meaning as in USP <825>.

(E) "Dangerous drug" has the same meaning as in section 4729.01 of the Revised Code.

(F) "Dispense" means the final association of a drug with a particular patient pursuant to a prescription, drug order, or other lawful order of a prescriber and the professional judgment of and the responsibility for interpreting, preparing, compounding, labeling, and packaging a specific drug.

(G) "Final check" means the final verification check for accuracy and conformity to the formula of the compounded preparation or product being prepared, correct ingredients and calculations, accurate and precise measurements, appropriate conditions and procedures, and appearance of the final product.

(H) "Kit" means a commercially manufactured package containing all ingredients required to prepare a radiopharmaceutical with the exception of the radionuclide.

(I) "Licensed health professional authorized to prescribe drugs" or "prescriber" has the same meaning as in rule 4729:5-1-02 of the Administrative Code but shall be limited to a prescriber practicing within the prescriber's applicable scope of practice.

(J) "Non-sterile compounded drug" means a dangerous drug preparation intended to be nonsterile.

(K) "Nuclear pharmacy" is a pharmacy licensed as a terminal distributor of dangerous drugs where prescriptions for radiopharmaceuticals are prepared, compounded, dispensed, or repackaged. A nuclear pharmacy shall also be licensed by the United States nuclear regulatory commission or the appropriate state nuclear regulatory agency.

(L) "Personal supervision" means the person specified in rule shall be physically present at the licensed location to provide personal review and approval of all professional activities.

(M)

(1) "Positive identification" means a method of identifying a person that does not rely on the use of a private personal identifier such as a password, but must use a secure means of identification such as the following:

(a) A manual signature on a hard copy record;

(b) A magnetic card reader;

(c) A bar code reader;

(d) A biometric method;

(e) A proximity badge reader;

(f) A board approved system of randomly generated personal questions;

(g) A printout of every transaction that is verified and manually signed within a reasonable period of time by the individual who prescribed, administered, or dispensed the dangerous drug. The printout must be maintained for three years and made readily retrievable; or

(h) Other effective methods for identifying individuals that have been approved by the board.

(2) A method relying on a magnetic card reader, a bar code reader, a proximity badge reader, or randomly generated questions for identification must also include a private personal identifier, such as a password, for entry into a secure mechanical or electronic system.

(N) "Preparing" or "preparation" means the act of combining a conventionally manufactured kit with a conventionally manufactured radionuclide following manufacturer's recommended instructions. Mixing, reconstituting, combining, diluting, or repackaging of a radiopharmaceutical, or other such acts, performed in accordance with directions contained in the FDA-approved labeling.

(O) "Preparation with minor deviation" means the act of preparing conventionally manufactured radionuclide with volume, and/or radioactivity, and/or step-by-step deviations from the manufactures recommended labeling while ensuring that the final preparation maintains appropriate radiochemical and radionuclidic purity for the entirety of the beyond-use date.

(P) "Product" means a drug in a commercially manufactured pharmaceutical dosage form that has been evaluated for safety and efficacy by the United States food and drug administration. Products are accompanied by full prescribing information, which is commonly known as the United States food and drug administration-approved manufacturer's labeling or product package insert.

(Q) "Readily retrievable" means that records maintained in accordance with this chapter shall be kept in such a manner that, upon request, they can be produced for review no later than three business days to an agent, officer or inspector of the board.

(R) "Responsible person" has the same meaning as defined in rule 4729:5-2-01 of the Administrative Code and is responsible for the supervision and control of dangerous drugs as required in division (B) of section 4729.55 of the Revised Code, adequate safeguards as required in division (C) of section 4729.55 of the Revised Code, security and control of dangerous drugs, and maintaining all drug records otherwise required.

(1) Except as provided in paragraph (R)(2) of this rule, a nuclear pharmacy shall have an authorized nuclear pharmacist as its responsible person. Responsible person shall also mean the "designated person" as used in USP 825.

(2) An institutional facility licensed as a terminal distributor of dangerous drugs with an on-site nuclear pharmacy that is engaged in the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals shall comply with the following:

(a) Submit notification to the board, in a manner determined by the board, that the facility is engaged in the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals.

(i) For new facilities, the institutional facility shall notify the board within ten days of the date the facility engages in the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals.

(ii) For existing facilities, the institutional facility shall notify the board within ten days of the effective date of this rule.

(b) A nuclear pharmacy that ceases to engage in the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals shall submit notification to the board, in a manner determined by the board, within ten days of cessation.

(c) The facility shall have a designated person who is an authorized nuclear pharmacist employed by the facility that is responsible and accountable for the performance and operation of the radiopharmaceutical processing facility and for personnel who prepare, prepare with minor deviation, compound, dispense, personally furnish, and repackage radiopharmaceuticals.

(i) For new facilities, the institutional facility shall notify the board of the designated person within ten days of the date the nuclear pharmacy in a facility engages in the preparation, preparation with minor deviation, compounding, dispensing, personally furnishing, or repackaging of radiopharmaceuticals.

(ii) For existing facilities, the institutional facility shall notify the board of the designated person within ten days of the effective date of this rule.

(iii) If there is a change in the designated person, the board shall be notified within ten days of the effective date of the appointment of the new designated person.

(S) "Sterile" means a dosage form free of living microorganisms (aseptic).

(T) "Sterile compounded drug" means a dangerous drug preparation intended to be sterile.

(U) "United States Pharmacopeia Chapter <825>" or "USP <825>" means United States Pharmacopeia Chapter <825>, USP 42-NF 37 2S, or any official supplement thereto (12/1/2020).

Last updated February 2, 2022 at 10:10 AM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 4729.01, 3719.01
Five Year Review Date: 2/1/2027
Prior Effective Dates: 4/1/1978, 9/1/1989, 2/1/2005
Rule 4729:5-6-02 | Applicability.
 

(A) The provisions in this chapter apply to the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals for humans and animals prepared by a pharmacy, including an institutional facility, licensed as a terminal distributor of dangerous drugs. These standards apply to all radiopharmaceuticals, including those with radionuclides that emit a single photon, a positron, or a therapeutic particle, and intravascular radioactive devices (e.g. radioactive microspheres).

(B) This chapter does not apply to the preparation, preparation with minor deviation, compounding, dispensing, personally furnishing, and repackaging of non-radioactive drugs, including those used as pharmacologic adjuncts for certain nuclear medicine procedures. These drugs shall be prepared in accordance with the applicable provisions of division 4729:7 of the Administrative Code.

(C) Except if specifically stated in this chapter, an outpatient pharmacy shall also comply with Chapter 4729:5-5 of the Administrative Code.

(D) Except if specifically stated in this chapter, an institutional pharmacy shall also comply with Chapter 4729:5-9 of the Administrative Code.

(E) Except if specifically stated in this chapter, a nonresident nuclear pharmacy shall comply with the requirements of rule 4729:5-8-05 of the Administrative Code.

(F) All terminal distributors of dangerous drugs engaged in the preparation, preparation with minor deviation, compounding, dispensing, or repackaging of radiopharmaceuticals for humans and animals shall comply with Chapter 3701:1-58 of the Administrative Code.

Last updated February 2, 2022 at 10:10 AM

Supplemental Information

Authorized By: 4729.26
Amplifies: 4729.54
Five Year Review Date: 2/1/2027
Rule 4729:5-6-03 | Preparation, compounding, labeling, dispensing, and repackaging of radiopharmaceuticals.
 

(A) A terminal distributor of dangerous drugs engaged in the preparation, compounding, dispensing, or repackaging of radiopharmaceuticals for humans and animals shall comply with USP <825>.

(B) All radiopharmaceuticals shall be dispensed pursuant to a patient-specific prescription issued by a licensed health professional authorized to prescribe drugs.

(1) A limited quantity may be prepared and distributed in anticipation of prescriptions based on routine, regularly observed prescribing patterns.

(2) In the event a patient's name is not available at the time of dispensing, a nuclear pharmacy shall have up to seventy-two hours to obtain the name of the patient. No later than seventy-two hours after dispensing the radiopharmaceutical, the patient's name must be associated with the prescription in the dispensing records maintained in accordance with rule 4729:5-6-04 of the Administrative Code.

(C) All radiopharmaceuticals are exempt from the labeling requirements of division 4729:5 of the Administrative Code.

(1) Radiopharmaceuticals shall be labeled in accordance with USP <825>.

(2) In addition to the requirements in paragraph (C)(1) of this rule, the outer shielding shall also be labeled with the following:

(a) The name and telephone number of the pharmacy;

(b) The prescription number; and

(c) The patient's name (first name and last name or first initial and last name), if available at the time of dispensing.

(3) In addition to the requirements in paragraph (C)(1) of this rule, the immediate container shall also be labeled with the following information:

(a) The prescription number; and

(b) The patient's name (first name and last name or first initial and last name), if available at the time of dispensing.

(D) A terminal distributor shall ensure that all employees comply with all applicable local, state, and federal requirements for the proper labeling, environmental controls, integrity, and safety of all products transported.

(E) A terminal distributor shall ensure that all employees comply with all applicable local, state, and federal requirements for the disposal of radioactive and/or biohazardous waste in a manner so as not to endanger the health and safety of the public.

(F) All personnel trained to work with radiopharmaceuticals shall do so under the personal supervision of an authorized nuclear pharmacist.

(G) A terminal distributor shall report any event as a medical event, except for an event that results from patient intervention, to the Ohio department of health in accordance with rule 3701:1-58-101 of the Administrative Code.

Last updated February 2, 2022 at 10:10 AM

Supplemental Information

Authorized By: 3715.69, 3719.28, 4729.26
Amplifies: 3715.64, 3719.08
Five Year Review Date: 2/1/2027
Rule 4729:5-6-04 | Record keeping.
 

(A) In addition to the applicable record keeping requirements of division 4729:5 of the Administrative Code, a terminal distributor shall maintain records in compliance with USP <825> for all activities involved in repackaging, preparing, preparing with minor deviations, compounding, or dispensing radiopharmaceuticals.

(B) In addition to the requirements set forth in paragraph (A) of this rule, there shall be positive identification of the authorized nuclear pharmacist conducting the final check of the radiopharmaceutical.

(C) All records maintained in accordance with this rule shall be readily retrievable and uniformly maintained for at least three years.

(1) Except as provided in paragraph (C)(2) of this rule, all records maintained in accordance with this chapter shall be kept on-site.

(2) A pharmacy located in this state intending to maintain records at a location other than the location licensed by the state board of pharmacy shall send a request in a manner determined by the board. The board will provide written or electronic notification to the outpatient pharmacy documenting the approval or denial of the request. A copy of the board's approval shall be maintained at the licensed location. Any such alternate location used to store records shall be secured and accessible only to authorized representatives or contractors of the terminal distributor of dangerous drugs.

(D) All records maintained pursuant to this chapter may be electronically created and maintained, provided that the system that creates and maintains the electronic record does so in accordance with the following:

(1) Complies with the requirements of this rule;

(2) All paper records maintained electronically shall be scanned in full color via technology designed to capture all information in the paper record in one form and reproduce it in an electronic medium presentable and usable to an end user;

(3) Contains security features, such as unique user names and passwords, to prevent unauthorized access to the records; and

(4) Contains daily back-up functionality to protect against record loss.

(E) All records required in accordance with this chapter shall be maintained under appropriate supervision and control to restrict unauthorized access.

Last updated February 2, 2022 at 10:10 AM

Supplemental Information

Authorized By: 4729.26
Amplifies: 4729.54, 4729.55, 4729.57
Five Year Review Date: 2/1/2027