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TPH Therapheutics
TPH Therapheutics
TPH Therapheutics
Document Name :
Date Created :
25 September 2016
Approved By :
SHELLEY ANN M. MANGAHAS, MD,
MHA, FPAO
OIC Chief of Hospital
Reviewed By :
MAITA P. RIGOR, MD, FPCS, FPSGS
Chief of Clinics
Issued By :
Responsibility of Updating :
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TABLE OF CONTENTS
NO.
PARTICULARS
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The Pharmacy and Therapeutics Committee is an advisory group of the medical staff
which serves as the organizational line of communication between the medical staff and
pharmacy department. It is a policy recommending body to the medical staff and the
administration of the hospital on matters related to drug use. This committee is composed
of physicians, pharmacists and other health professionals elected with the guidance of the
medical staff.
2. THE PURPOSE OF PHARMACY AND THERAPEUTICS COMMITTEE (PTC)
2.1
ADVISORY
The committee recommends the adoption of, or assists in the formulation of, broad
professional policies regarding evaluation, selection and therapeutic use of drugs in
hospitals.
2.2
EDUCATIONAL
The committee recommends or assists in the formulation of programs assigned to
meet the needs of the professional staff (physicians, nurses, pharmacists and other
health care practitioners) for complete current knowledge on matters related to
drugs and drug use.
(2)
(3)
The committee should meet regularly at least six times per year, and when
necessary.
(4)
The committee should invite to its meeting persons within or outside the hospital
who can contribute specialized or unique knowledge, skills and judgments.
(5)
(6)
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(7)
(8)
Liaison with other hospital committee concerned with drug use (e.g. infection
control, medical audit) shall be maintained.
(2)
To develop a formulary of drugs accepted for use in the organization and provide
for its constant revision.
(3)
To establish programs and procedures that help ensure safe and effective drug
therapy.
(4)
To establish programs and procedures that help ensure cost effective drug therapy.
(5)
(6)
(7)
To monitor and evaluate ADRs in the health care setting and to make appropriate
recommendations to prevent their occurrence
(8)
To initiate or direct (or both) drug use evaluation program and studies, review the
results of such activities, and make appropriate recommendations to optimize drug
use.
(9)
Proposal for a new drug for the hospital formulary shall be submitted on a
Formulary Request Form. Such request may be submitted by any member of the
medical staff. The Committee will evaluate the request and notify the proposer as to
acceptance or rejection. The proposer shall have the opportunity to appeal the
decision of the Committee.
5.2
Drugs evaluated and approved by the Committee will be assigned to one of the four
(4) categories:
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5.2.1
Formulary Drug
An BFAD approved drug which is recommended as being essential for good
patient care with a well-established usage. Once accepted as a Formulary
Drug, it may be prescribed by all members of the attending and house staff.
5.2.2
5.2.3
5.2.4
Investigational Drugs
A drug which has been approved by the FDA for a special use by its
principal investigator and designated associates. Such drugs are not
commercially available. A protocol of the study must be submitted to the
pharmacy if it is to be used in the hospital.
The drugs are not necessarily a new chemical substance but may be:
(1)
(2)
(3)
(4)
5.3
Non Formulary Drugs are drugs which do not qualify for the four categories listed
and will not be stocked in the pharmacy. If prescribed the Pharmacy will obtain and
dispense a limited quantity of the drug.
5.4
The pre-signing of prescription blanks or drug orders for any purpose is prohibited.
5.5
Formulary system dictates that all drugs will be dispensed on the basis of generic
names. Authority for the routine selection of the drug brands is delegated to the
Pharmacy Department utilizing a fair and equitable bid process, when necessary.
5.6
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5.7
In Patient Prescribing
5.7.1
5.7.2
IV Orders
Orders for intravenous medications must be written in the same manner as
routine drugs and must include then following additional information:
a) The exact quantity of the drug/s which must be added.
b) The exact volume and name of the infusate solution.
c) Specific directions for administration such as IV drip, IV bolus, IV push,
etc.
d) Specific times to hang infusate solution and drip rate.
e) Specific directions for continuing or discontinuing any IV medications.
5.7.3
Ordering
The TPN mixture may only be prescribed by an authorized
House Staff physician in conjunction with a Dietician through
consultation.
The written order must be sent to the Pharmacy for verification
including the basic solution and all additives.
Following the original order, subsequent orders must be
confirmed every morning and recorded on a card designated for
that specific patient.
A 24 hour supply is to be ordered by the physician each
morning.
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Self-Medication
Only nitroglycerin and antacids may be left at the patient's bedside for selfadministration if so ordered by the physician. The quantity of nitroglycerin
is limited to 10 tablets which must be counted by the nurse at the conclusion
of each shift and charted in the patient's medical record. Antacids must be
recorded and replenished in the same manner.
5.7.5
5.7.5.2
5.8
5.9
Discharge Prescriptions
A separate prescription is required for each medication which the patient is to take
home. Discharge prescriptions must be received in the Pharmacy prior to discharge,
so that they may be processed and returned to the nursing station. Delays may result
in the patient having to wait which is not consistent may result good patient care.
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The primary objective of the formulary is to provide the hospital staff with:
1) Information on what drug products have been approved by the pharmacy and
therapeutics committee.
2) Basic therapeutic information about each approved item.
3) Information on hospital policies and procedures governing the use of drugs.
4) Special information about drugs such as drug dosing rules monograms, hospital
approved abbreviations, etc.
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7.2
In accordance with these objectives, the formulary should consist of three main
parts:
PART I Information on hospital policies and procedures concerning drugs
PART II Drug products listings
PART III Special Information
7.2.1
7.2.2
7.2.3
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8.1
CRITERIA
(1) Drugs must be of proven clinical value based upon experience.
(2) The drugs must be recognized by BFAD or their supplement.
(3) The manufacturers of these drugs must be of proven integrity and dependability
as well as having the regulation of initiating and supporting research activities
of merits.
(4) No preparation of secret composition will be considered or admitted to the
formulary.
(5) No product of multiple composition shall be admitted if the same therapeutic
value can be obtained through the use of a single drug entity.
** NOTHING FOLLOWS **
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