Pharmacy & Therapeutics Committee

Terms of Reference
Purpose:
1. overall hospital pharmacy and therapeutic functions (formulary maintenance, safe
medication use, and medication use evaluation) and to review drug utilization and
effectiveness.
2. Formulate and review policies regarding the selection, regulation, distribution, storage,
safe use and administration of drugs within the hospital.

Activities:
1- Serve in evaluative, educational and advisory capacity to the medical staff and hospital
management in all matters pertaining to the use of medications.
2- Develop and approve criteria for selecting medications that include at least indications,
effectiveness, risks (potential for medication errors, abuse potential, and sentinel
events), or cost.
3- Develop a formulary of drugs accepted for use in the hospital and provide for its
constant revision.
4- Establish programs and procedures that help ensure safe, effective and cost-effective
drug therapy.
5- Establish or plan suitable educational programs for the hospital's professional staff on
matters related to drug use.
6- Participate in quality improvement activities related to distribution, administration, and
use of medications.
7- Monitor and evaluate adverse drug events and make appropriate recommendations to
prevent their recurrence.
8- Establish evidence-based therapeutic guidelines according to the scope of services of
the hospital (e.g. intravenous iron, intravenous immunoglobulin, albumin, heparin,
chemo protocols, high alert medications, and electrolyte management guidelines).
9- Initiate and/or direct drug use evaluation programs and studies, review the results of
such activities, and make appropriate recommendations to optimize drug use.
10- Advise the pharmaceutical care department in the implementation of effective drug
distribution and control procedures.
11- Disseminate information on its actions and approved recommendations to all staff.
12- The committee conducts an annual review of its hospital formulary based on safety and
efficacy information (e.g., Saudi FDA warnings, international medication safety alerts,
hospital-based adverse drug reaction reports, and drug utilization evaluation studies)
13- Regular review of non-formulary drug requests

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14- The pharmacy and therapeutics committee develops and approves medication
substitution protocols in the event of medication shortage or outage.
15- The antibiotics guidelines are updated as recommended by the pharmacy and
therapeutics committee utilizing the hospital anti-biogram.
16- The pharmacy and therapeutics committee reviews and monitors all cases of using non-
formulary medication and all cases of using formulary medication for unapproved
indication or investigation.
17- Recommends actions for improvement and evaluates their effectiveness.

Membership:
1- Medical Director. (Chairman)
2- Head of Pharmacy Department. (Co-chairman)
3- Clinical Pharmacist.
4- Medication & Medical Supply Storage Supervisor.
5- Head of internal Medicine Department.
6- Head of Surgery Department.
7- Head of Obstetrics & Gynecology Department.
8- Head of Pediatrics, PICU & NICU Department.
9- infection Control Coordinator.
10- Head of Ql & PS Department.
11- Nursing Director.

• Frequency of meetings:
Monthly and / as required (at least Quarterly)

• Quorum
75% of the members are required to hold the meeting

• Distribution of minutes
▪ To General Director
▪ To Quality improvement & Patient Safety Department
▪ To be saved in the committee archive
• Mechanism of disagreement resolution:
▪ The committee members can make voting as a mechanism of disagreement
resolution
▪ The invited members are not allowed to vote

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Approved by:
Name: Title: Head of Pharmacy Department
Signature: Date:

Name: Title: Quality director

Signature: Date:

Name: Title: Medical Director

Signature: Date:

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