AuthoritytoAdministerImmunizations/Vaccines

(Name of Pharmacist),PharmacyLicense# (list all pharmacists who will be administering medications or attach a list with their name and license number) actingas delegatedagentfor theundersigned physician,accordingtoandincompliancewithStatute17-92-101 andRegulation09-00-0002, may selectandadministerImmunizations/Vaccineslistedbelowon thepremisesof the(Name of thePharmacy)(or elsewhere)andfor afee.

Toprotectpeoplefrompreventableinfectiousdiseasethatcauseneedlessdeathanddisease,this pharmacistmayselectandadministerthefollowingimmunizations/vaccinationstoeligiblepatientsaccording to Arkansas Pharmacy Regulations andaccordingtoindicationsandcontraindicationsrecommendedincurrentguidelines fromtheAdvisory Committeeon ImmunizationPracticesof theCenterfor DiseaseControland Preventionandothercompetentauthorities:

Medication / Dose / Route

In thecourseof treatinganadverseeffectfollowingimmunization/vaccination,thispharmacistis authorizedtoadministerthefollowingmedicationspendingthearrivalof emergencymedicalservices:

MedicationClass / Medication / Dose / Route
AllergyMedications / Epinephrine / ~0.01 mg/kg/dose
(maximum0.5mg/dose) / SQ or IM

Thepharmacistwillmaintaincurrentcertificationincardiopulmonaryresuscitation(Dateof

certification: ).

In thecourseof immunizing/vaccinating,thispharmacistmustmaintainperpetualrecordsof all immunizations/vaccinationsadministered.Beforeimmunization/vaccination,allimmunization/vaccine candidateswillbequestionedregarding1) previousadverseeffectsrelatedtoimmunization/vaccination,

2) food anddrug allergies,3) currenthealth,4)immunefunction(i.e.,immunosuppression),5) recent receiptof bloodor antibodyproducts,6) pregnancy(ifapplicable),and7) underlyingdiseases.All vaccinecandidateswillbeinformedof thespecificbenefitsandrisks of theimmunization/vaccination offered.Allimmunization/vaccinerecipientswillbeobservedfor asuitableperiodafter immunization/vaccinationfor adverseeffects.

Allimmunization/vaccinerecipientswillbeofferedwrittendocumentationof immunization/vaccination administration.Theimmunization/vaccinationmaybereportedtothepatient’sprimarycareprovider and totheappropriatecountyor stateimmunization/vaccinationregistries.

Thepharmacistwillendeavornottodisruptexistingpatient-physicianrelationships.Thepharmacist

willreferpatientsneedingmedicalconsultationtoaphysician.Thepharmacistwillmakespecialefforts toidentifysusceptiblepeoplewho havenotpreviouslybeenofferedimmunization/vaccination.

Protocol from the Arkansas State Board of Pharmacy website ( on February 28, 2012

AuthoritytoAdministerImmunizations/Vaccines,continued

As theauthorizingphysician,I havereviewedthisAuthoritytoAdministerImmunization/Vaccination andagreewithitscontent.Thisdocumentisvalidfor oneyear,unless revokedinwritingsooner.

Physician Name:

MedicalLicense#:

Address:

City: , ArkansasZipcode:

PhysicianSignature:

Date: ______

Protocol from the Arkansas State Board of Pharmacy website ( on February 28, 2012

ProtocolforManagementof SevereAllergic/AnaphylacticReactions

GENERAL:

Takeathoroughhistoryfor allergiesandprioradverseeventsbeforeanyadministeredmedications.

Allow adequatephysicalspacefor faintingor collapsewithoutinjuryandtolaypatientflaton ahard surfaceintheeventcardiopulmonaryresuscitation(CPR) isneeded.

Maintaincurrentcompetencyin medicationadministered;observeallrecipientsfor asuitableperiod afteradministration;remindrecipienttoreportanyadverseeventstoyou.

Bepreparedtocall911

SUPPLIES TO STOCK:

Epinephrine– invialsor pre-filledsyringes;maintainsupplyfor two doses perevent.

Diphenhydramine– injectableandoralliquid.

Syringes, needles,etc– suppliesnecessarytodeliverepinephrineanddiphenhydramine

Blood-pressurecuffandstethoscope

RECOGNITION OF ANAPHYLACTIC REACTION:

Sudden onsetof itching,redness, withor withouthives,withinseveralminutesof administeringa medication.Thesymptomsmaybelocalizedor general.

Swellingof thelips,face,andthroat(angioedema)

Bronchospasm,shock

EMERGENCY TREATMENT:

1. If itchingandswellingareconfinedtotheextremitywherethemedicationwas given,observe patientcloselyfor asuitableperiod,watchingfor generalizedsymptoms.If noneoccur,go to7.

2. If symptomsaregeneralized,activatetheemergencymedicalsystem(EMS) (e.g.,call911), andcall theconsultingphysicianfor instructions.Anotherperson shoulddo this,whilethepharmacisttreats andobserves thepatient.

3. Administerepinephrine0.5 mg,SQ or IM. May administerintheanteriorthighor deltoidmuscle.

4. Administerdiphenhydramine50-100 mg,IM. Do NOT administerdiphenhydramineor anyother drug by mouthifthepatientisnotfullyalertor ifthepatienthas respiratorydistress.

5. MonitorthepatientcloselyuntilEMS arrives.PerformCPR andmaintainairwayifnecessary.

Keeppatientinsupinepositionunless theyarehavingbreathingdifficulty.If breathingisdifficult, patient’sheadmaybeelevated,providedbloodpressure isadequatetopreventloss of consciousness. Monitorvitalsigns frequently.

6. IfEMS has notarrivedandsymptomsarestillpresent,repeatdose ofepinephrineevery5 to20 minutes,dependingon patient’sresponse.

7. Patientmustbereferredfor medicalevaluation,evenifsymptomsresolvecompletely.Symptoms mayreoccurafterepinephrineanddiphenhydraminewearoff, as muchas 24 hours later.Afterthe eventisconcluded,completeaVAERS form.

Protocol from the Arkansas State Board of Pharmacy website ( on February 28, 2012