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TITLE 22EXAMINING BOARDS
PART 15TEXAS STATE BOARD OF PHARMACY
CHAPTER 291PHARMACIES
SUBCHAPTER GSERVICES PROVIDED BY PHARMACIES
RULE §291.131Pharmacies Compounding Non-Sterile Preparations

        (II) practitioner's name, address, and name of the Class C pharmacy, if applicable;

        (III) name, strength, and quantity of the preparation in each container of the preparation;

        (IV) name and quantity of each active ingredient;

        (V) quantity of containers distributed; and

        (VI) pharmacy's lot number;

  (4) Labeling. The pharmacy shall affix a label to the preparation containing the following information:

    (A) name, address, and phone number of the compounding pharmacy;

    (B) the statement: "For Institutional or Office Use Only--Not for Resale"; or if the preparation is distributed to a veterinarian the statement: "Compounded Preparation";

    (C) name and strength of the preparation or list of the active ingredients and strengths;

    (D) pharmacy's lot number;

    (E) beyond-use date as determined by the pharmacist using appropriate documented criteria;

    (F) quantity or amount in the container;

    (G) appropriate ancillary instructions, such as storage instructions or cautionary statements, including hazardous drug warning labels where appropriate; and

    (H) device-specific instructions, where appropriate.

(g) Recall Procedures.

  (1) The pharmacy shall have written procedures for the recall of any compounded non-sterile preparations provided to a patient, to a practitioner for office use, or a pharmacy for administration. Written procedures shall include, but not be limited to, the requirements as specified in paragraph (3) of this subsection.

  (2) The pharmacy shall immediately initiate a recall of any non-sterile preparation compounded by the pharmacy upon identification of a potential or confirmed harm to a patient.

  (3) In the event of a recall, the pharmacist-in-charge shall ensure that:

    (A) each practitioner, facility, and/or pharmacy to which the preparation was distributed is notified, in writing, of the recall;

    (B) each patient to whom the preparation was dispensed is notified, in writing, of the recall;

    (C) if the preparation is prepared as a batch, the board is notified of the recall, in writing;

    (D) if the preparation is distributed for office use, the Texas Department of State Health Services, Drugs and Medical Devices Group, is notified of the recall, in writing;

    (E) the preparation is quarantined; and

    (F) the pharmacy keeps a written record of the recall including all actions taken to notify all parties and steps taken to ensure corrective measures.

  (4) If a pharmacy fails to initiate a recall, the board may require a pharmacy to initiate a recall if there is potential for or confirmed harm to a patient.


Source Note: The provisions of this §291.131 adopted to be effective September 18, 2007, 32 TexReg 6352; amended to be effective March 6, 2008, 33 TexReg 1801; amended to be effective September 9, 2012, 37 TexReg 6917; amended to be effective January 4, 2018, 42 TexReg 7700; amended to be effective August 24, 2022, 47 TexReg 4977

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