Effective Date: 
Wed, 09/15/2004
Tue, 04/24/2018
Tue, 04/24/2018

The California State Board of Pharmacy requires pharmacies and health care facilities to have a Quality Assurance program to study and evaluate prescription errors in order to prevent recurrence of such errors.

The pharmacy abides by established policies and develops new policies or systems in an effort to reduce medication errors.

Any medication error is documented on a Pharmacy Medication Error Report and Review and is reported to the Quality Management Committee. Documentation also complies with the SHS Risk Managment policy.  This information is not discoverable.


The pharmacist reviews every prescription for the following: Name, Date, Drug, Dose, Quantity, Directions, Signature, and Refills.

In addition, the pharmacist reviews the patient profile for drug interactions and/or duplications etc.

Any problems or questions with drug therapy or understandability or completeness of the prescription are addressed with the prescriber prior to filling the prescription.

The pharmacist ascertains that the patient is the one listed on the prescription and is the correct patient in the pharmacy computer system.

The prescription is filled appropriately and the patient receives the prescription, the appropriate paperwork and counseling.

In the event of a medication error (Definition: any variation from a prescription or drug order not corrected prior to furnishing the drug to the patient – generic and dosage form substitutions are not errors), the Pharmacy Medication Error Report and Review is filed. That report contains the name of the patient and the prescriber, the date and the facts. The patient and the presciber are notified of the error. This report is the start of an investigation. All errors are reviewed as soon as reasonably possible, but no later than two business days from date of discovery. 

That review includes:

  1. Date, location and participants in the review.
  2. Pertinent data and other information relating to the medication error(s) reviewed.
  3. Documentation of patient and prescriber notification.
  4. Findings and determinations generated by the quality assurance review.
  5. Recommended changes to pharmacy policy, procedure, systems, or processes, if any.

The policy and plan are available and readily retrievable in the pharmacy. The records are kept in the pharmacy and retained for at least one year from creation.

The review is standardized in a format to include the above information (linked) and is presented to the Quality Management Committee periodically.

The review itself may generate changes that may be implemented immediately. Those changes are documented in the review as well.

The Quality Management Committee may also recommend changes. Implementation of those changes is documented on the review when accomplished.

See: Incident Report


Effective Date: 
Wed, 01/01/2003
Fri, 05/15/2015
Fri, 05/15/2015
The UCSC Student Health Center supports a team of providers to care for students with eating disorders.  
Specific medical, nursing, psychiatric, counseling and nutrition staff members are designated to provide care for ED students.   The team meets monthly during the fall, winter and spring quarters  to discuss management of specific cases, support one another in providing care, and keep up-to-date on best practices in the care of the eating disordered patient. Off campus therapists who work most closely with our eating disordered patients are invited to join this monthly meeting.
The Patient Care Coordinator chairs the Eating Disorder Care Team.  The PCC regularly reviews the EMR to identify active ED students and providers extra support to ED students requiring active surveillance.  
The role of the Student Health Center in the care of the Eating Disordered patient is identification of students with Eating Disorders, appropriate evaluation for medical complications, and referral for psychological counseling.  
The Student Health Center does not provide intensive outpatient services. 
In cases where more intensive medical care, exceeding the capacity of the Student Health Center ,is required.the Patient Care Coordinator works with the therapist, the patient, and the family to identify a more appropriate source of care.
In cases where a patient fails to agree to recommendations for a higher level of care,the policy on Involuntary Medical Withdrawal outlines the specific steps to be taken when an Eating Disordered student is unable to safely care for themselves and must be asked to leave school.  
Students with eatings disorders are identified by providers or present themselves for care. 
This diagnosis is entered onto the patient's Problem List. 
If the initial visit was with a provider not on the ED Team then follow up should be scheduled with a clinician on the ED team.   
A 40 minute intake appointment is made with a medical member of the ED Team for an initial evaluation. 
The clinician should specifically document the patients medical acuity. 
Every attempt should be made to link patients to mental health care.  If possible, a Release of Information to work with the therapist should be obtained.   
Frequency of follow-up visits with the clinician is based on clinician and therapist levels of concern. 
The student should be encouraged to use the additional services available at the Student Health Center including both the services of our nutritionist and the opportunity to join the Eating Awareness group run by CAPS.  
If appropriate, a psychiatric evaluation may be scheduled.  
The Patient Care Coordinator facilitates a monthly meeting of those professional staff working with Eating Disordered students.  
These meetings include a continuing education component, an opportunity to discuss difficult situations, and a review of high acuity cases.  The meeting includes an opportunity to seek help with difficult situations from oher colleagues. 
If a clinician determines that a student's eating disorder has reached a life threatening acuity or their behavior puts them at grave danger, the clinician may request that an Ad Hoc Committee be convened to consider requesting that the student be placed on involuntary medical leave in order to receive a higher level of care.   This process is delineated in the policy on Involuntary Medical Withdrawal.  
The Patient Care Coordinator works with the families of Eating Disordered students as necessary to help identify an appropriate plan of care, including hospitalization.
Key Points: 
  • Specific providers in the Student Health Center care for students with Eating Disorders. 
  • These providers make up the Eating Disorder Care Team which meets monthly for continuing education, support, and clinical case review to maintain a high level of quality care for the eating disordered student. 
  • The Student Health Center clinicians monitor physical complications due to eating disorders but recognizes that therapy is the cornerstone of treatment for eating disorders.  Clinicians collaborate with the student's therapist to provide care..  
  • In the event that a clinician feels that a students condition is grave or life threatening, every attempt should be made to facilitate moving the student to a higher level of care.  If these attempts are unsuccessful, an Ad Hoc Committee can be convened to consider placing the student under Involuntary Medical Withdrawal.
  • The Patient Care Coordinator regularly reviews the EMR to identify Eating Disorder students and to review acuity. 
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