Sop-2022 1st Revision

Rafael Lazatin Memorial Medical STANDARD OPERATING SOP No: 01
Center PROCEDURE
Revision: January 15, 2022 DRUG SELECTION FOR Effectivity date: January 23, 2022
Review Date: December 12, 2021 HOSPITAL FORMULARY Page No. 1 of 1
I. OBJECTIVE
This procedure is established to ensure that affordable, safe, quality, and efficacious drug
products.
II. SCOPE
The procedure shall strictly follow the hospital formulary when Licensed Physicians
prescribed medicines.
III. RESPONSIBILITY
The Pharmacy and Therapeutics committee together with the clinical departments shall
be the one to select the drugs to be inserted in the hospital formulary with respect to the
Philippine National Formulary.
IV. PROCESS DESCRIPTION
• Each department shall prepare a list of drug products based on their clinical practice guidelines
• All list of drug products shall be submitted to the Pharmacy Department
• The Pharmacy shall consolidate and narrow down drug products.
Drug products included in the list are verified if:
Included in Philippine National Formulary - Executive Order (EO) No. 49 series of 1993
• The Pharmacist further evaluates and reviews the consolidated list, based on the historical
consumption of each drug product.
• The Pharmacist shall present the reconciled list (including the price, and allotted budget) of
drugs and medicines to the PTC for deliberation and recommendation.
• Once approved, the list shall become the final Annual Procurement Management Plan (APMP)
for the following calendar year.
• The final APMP shall then be included in the Annual Procurement Plan of the hospital for the
following calendar year.
• The Hospital Formulary shall be reviewed at least once a year for revisions
V. END OF DOCUMENT
Prepared by: Reviewed by: Approved by:
MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Center PROCEDURE
Revision: January 15, 2022 Effectivity date: January 23, 2022

POCUREMENT OF STOCKS
Review Date: December 12, 2021 Page No.1 of 4
I. OBJECTIVE
This procedure is established to provide a step by step guideline in the procurement of

stocks through public bidding and emergency purchase.
II. SCOPE
This procedure shall be implemented quarterly or whenever funds are ready to use so that
drugs and medicines will be available to patients in the hospital.
III. RESPONSIBILITY
The Head of the Pharmacy prepares the purchase request. It is then submitted to the Head
of the Supply Service for processing.
1 – Purchase through Public Bidding
• The requisitioner (pharmacist) prepares the order for medicines in generic nomenclature
with complete dosage form and required specifications.
• The order is then submitted to the supply officer who will prepare the purchase request
typed and signed by the Chief of Hospital. All documents relating to procurement and
disbursement such as bid forms, vouchers and others shall specify medicines in generic
names. This shall cover both bidding and emergency procurement.
• The expediter submits the purchase request to the Office of the General Services Officer.
• The General Services Officer issues the memo for the schedule of the bidding.
• On the day of the bidding, Chief of Hospital issues a Letter of Authorization authorizing
the pharmacist to attend the bidding in his behalf.
• The bidding is held at the City Mayor’s Office or at the office of the General Services
Officer, City Hall, Pulong Maragul, Angeles City.
• The Letter of Authorization is submitted to the Bids and Awards Committee (BAC)
composed of the following: Chairman, Vice Chairman, three (3) BAC members, the City
Engineer, City Budget Officer, City Treasurer, Head-BAC TWG and the Requisitioner-
Chief of Hospital.
Center PROCEDURE

PROCEDURE
• Register at the attendance sheet – the Bids and Awards Committee, requisitioner and the
registered bidders.
• Roll call if the Bids and Awards Committee, requisitioner and registered bidders are
present.
• Explanation of the rules of the bidding by the BAC Chairman.
• Opening of Envelop 1 (one) of each bidder which contains all the technical documents by
the Chairman. A bidder who submits incorrect and incomplete requirements will be
automatically disqualified from the bidding.
• Opening of Envelop 2 which contains the filled BID FORMS of the bidders by the Vice
Chairman.
• After all the bid forms are opened, the prices are posted at the Abstract of Bids by the
staff of the General Services Office.
• After posting, the Abstract of Bids are then passed to the requisitioner (pharmacist) for
questions regarding the items bidded if any, and marking the price of the lowest bidder.
• After marking, the Abstract of Bids are given to the bidders so they can copy the items
awarded to them.
In making the award, the following factors should be considered:
• Conformity with the specifications stated in the invitation to bid.

• Reliability of the bidder as suppliers. The ability of the bidder to deliver within the
period stipulated in the invitation to bid.
• In case of tie offers and the items are divisible; the award will be divided equally. If
they are not divisible the Bids and Awards Committee will make the decision.
• As a rule, awards are given to the lowest winning bidder, unless the bidded item has
been used or tested before and rejected by the end users. The award is given to the
next lowest bidder.
• The General Services Office staff will prepare the purchase order and notice of
award. They are issued to the winning bidders and the requisitioner after the papers
are signed by the City General Services Officer, Chief Accountant and the City
Mayor.
Center PROCEDURE

2 – Purchase by Emergency Purchase
Emergency purchases are allowed only in cases where the need for medicines,
I.V. fluids is exceptionally urgent or absolutely indispensable to prevent immediate
danger to, or loss of life or to avoid detriment to public service. They should be based on
a canvass of prices of at three (3) bona fide dealers.
PROCEDURE:
• The requisitioner (pharmacist) submits the list of medicines, I.V. fluids in generic name
with complete dosage form to the supply officer.
• The supply officer prepares the purchase request, have it sign by the Chief of Hospital.
• The expediter submits the purchase request to the General Services Office, at the City
Hall. This office prepares the canvass of prices of at least three bona fide suppliers. It is
this office that processes all our requisitions. When the process is fully accomplished, a
purchase order is given to the requisitioner to inform the winning supplier for delivery of
the said drugs.
REVISION:
Same procedure as above except that the mode of procurement is not per item but by lot. The
supplier must make a bid on all the requested items, failure to do so will be a ground for outright
disqualification. The bidder with the lowest total amount and does not exceed the approved budget
contract (ABC) will be awarded the contract to deliver the goods.
Center PROCEDURE

3 –Purchase by Emergency Purchase through Petty Cash

Emergency purchases through petty cash are allowed in cases where there are no
available alternative drugs. They should be based on a canvass of prices of at least three
(3) drugstores . The drug should be listed in the Philippine National Formulary or
Hospital Formulary, whichever is available.
PROCEDURE:
• The pharmacist receives the prescription needed to be purchased.
• The pharmacist will canvass at least three (3) drugstores for the drug that is needed. After
the canvass, he/she will choose which is the most affordable of the three. An official
receipt must be available for filing the drug for the petty cash vouchers.
• The pharmacist encodes the medication in the system for the nurse to request.
V. END OF DOCUMENT

Center PROCEDURE

RECIEVEING OF STOCKS
Review Date: December 12, 2021 Page No. 1 of 1
I. OBJECTIVE
This procedure is established to ensure that received drugs are correct (in generic name,
strength, route of administration, expiration), in good condition, and corresponds to the stocks
procured.
II. SCOPE
This procedure is implemented whenever procured drugs are delivered at the pharmacy
except when purchased through petty cash.
III. RESPONSIBILITY
The Chief Pharmacist with the help of the staff inspects and checks the deliveries of
stocks.
• The Chief Pharmacist matches the documents from the supplier
• The winning bidder contacts the chief pharmacist to coordinate the date for delivery
• A secure, conspicuous space must be identified for the storage of the deliveries
• The Pharmacist receives the delivery receipt.
• The staff conducts physical check of every item supplied in the line with the specification.
• The Pharmacist then checks if the supplied items matches the specifications in the delivery
receipt
• The Intravenous Fluids deliverables will be put on the storage room with the instructions of the
pharmacist, while the other stocks will be arranged by the staff.
• Temperature sensitive medicines must be stored in the proper storage immediately
• The staff adds the deliveries in the Inventory, and in the system (iHOMIS) or the system
currently being used.
• The Staff then checks the Purchase Order/ Purchase Request of the corresponding deliveries to
check if the quantity is correct and/or in line with the request.
• The Delivery Receipt then must be kept in a folder with a compilation of the same documents.
V. END OF DOCUMENT

Center PROCEDURE

GOOD STORAGE PRACTICE
I. OBJECTIVE
This procedure is established to provide a written guideline on the effective way of

handling the proper storage of medicine.
II. SCOPE
This procedure is regularly implemented to protect the quality and potency of drugs through
good storage practice of the section.
III. RESPONSIBILITY
The pharmacy staff monitors are should be knowledgeable on good storage practice,
regulations, procedures, and safety
A. Pharmacy Storage room
• Storage areas should have a sufficient space to orderly store pharmaceutical products.
• It should be clean and dry and maintained within acceptable temperature limits, suitably spaced,
with pallets which are clean and in good state.
• The “First expiry/ First out” (FEFO) principle should be followed.
• Storage areas should provide adequate lighting to enable all operations to be carried out
accurately and safely
• Storage conditions for pharmaceutical products and materials should be in compliance with the
labelling
• Recorded temperature monitoring data should be available for review
• Equipment used for monitoring should be calibrated by a bona fide agency. Interval should be a
month before or during the equipment is last calibrated.
B. Dangerous Drugs Storage
• Storage of controlled substances must be in a limited access cabinet.

• Controlled substances must be stored separately from non-dangerous drugs
• The cabinet should have two (2) padlocks and should be kept close at all times.
Center PROCEDURE

GOOD STORAGE PRACTICE
C. Storage of Biological products, vaccines and other drug products

with low temperature requirement
• There should be sufficient biological refrigerators or improvised ordinary refrigerators to store

all necessary biologicals products, parenterals, suppositories and other products requiring
refrigeration
• Cold chain system is implemented to ensure the potency of a vaccine from the time of
manufacture to the time it is given to the patient.
• Vaccines with the earliest expiration date should be dispensed or used first.
• Equipment used for monitoring should be calibrated by a bona fide agency. Interval should be a
month before or during the equipment is last calibrated.
TEMPERATURE CONTROL
A. Pharmacy Store-room
• Pharmacy Area – Less than 30°C
• Warehouse Storage Area - for storage of medical supplies and intravenous fluids = Less
than 30’C
• Refrigerated Storage – contains drugs requiring regular refrigeration, and drugs that
cannot tolerate excessive handling or heat (2-25°C)
• Freezer – contains drug products that need below the freezing point,
V. END OF DOCUMENT

Center PROCEDURE
Revision: January 16, 2022 PEST CONTROL AND Effectivity date: January 23, 2022
Review Date: December 12, 2021 CLEANING Page No. 1 of 2
I. OBJECTIVE
To provide guidance on keeping the pharmacy and the storage room clean and pest free at all
times
II. SCOPE
This procedure is regularly implemented to protect the quality and potency of drugs through
cleanliness of the section.
III. RESPONSIBILITY
The housekeeping personnel are responsible in implementing the procedure on garbage

collection and pest control
A. PEST CONTROL
• Make sure that exterior openings are closed appropriately

• A delegated person shall perform a thorough examination of the premises
• Identify factors which favor breeding and habitation of pests (i.e. food and water)
• An appropriate pesticide will be used for the removal of pests
• This shall be done at least twice a month.
B. CLEANING
I. GARBAGE DISPOSAL
• The pharmacy section has separate containers for dry and wet waste.
• A Garbage bag must be used in the trash bin for ease of disposal
• The housekeeping personnel on duty collect the garbage two (2) times a day.
• Cleaning of the bins may be done if necessary.
Center PROCEDURE
Revision: January 16, 2022 PEST CONTROL AND Effectivity date: January 23, 2022
Review Date: December 12, 2021 CLEANING Page No. 2 of 2
II. SWEEPING AND MOPPING

• A delegated person shall sweep the floor using a broom at least once a day preferably in the
morning.
• After sweeping, the floor will be mopped if necessary.
• Additional sweeping may be done after mopping if there is still dust.
V. END OF DOCUMENT

Center PROCEDURE
Revision: January 17, 2022 DISTRIBUTION OF STOCKS Effectivity date: January 23, 2022
TO DIFFERENT
Review Date: December 12, 2021 STATIONS/AREAS Page No. 1 of 1
I. OBJECTIVE
This procedure is established to provide the availability of stocks to the different areas or
departments.
II. SCOPE
This procedure is implemented so that emergency medicines are always available at the
different sections.
III. RESPONSIBILITY
Emergency medicines are requested by the staff of each unit as needed. The Pharmacist
on Duty counterchecks their floor stocks as well as their expiration dates.
• Emergency medicines, and intravenous fluids are requested as needed by the staff on duty of
each department, Stations 1, 2, 3,4,5, Delivery Room, Emergency Room, Operating Room, and
OB-ER.
• The pharmacy staff on duty posts the requested medicines, intravenous fluids on the, iHOMIS
(or the electronic system being currently used), stock cards (if available), for monitoring and
inventory.
• The medicines, intravenous fluids requested by the different departments are listed in a logbook
and the nurse on duty inventories the items every endorsement of each shift daily.
• The pharmacist on duty regularly counterchecks the floor stocks at the

Nurse’s Stations, Delivery Room, Emergency Room, Operating Room, and OB-ER.
V. END OF DOCUMENT

Rafael Lazatin Memorial STANDARD OPERATING SOP No: 07
Medical Center PROCEDURE
Revision: January 17, 2022 Effectivity date: Jan.23,2022
Review Date: December 12, GOOD DISPENSING PRACTICE Page No. 1 of 2

2021
I. OBJECTIVE
This procedure is established to follow the guidelines set by the concerned government agencies
in the proper ways of dispensing medicines.
II. SCOPE
The procedure is implemented when Licensed Physicians prescribed medicines.
III. RESPONSIBILITY
The prescribing Physician and the Nurse on Duty follows all the rules in writing the prescription
and computerized ordering. The Pharmacist on Duty sees to it that the procedure is performed correctly.
I. INDIVIDUAL PRESCRIPTION ORDER

• All medicines are retained in the pharmacy until the physician’s initial order.
• The physician then orders the medicines needed for the patient. It may be a written prescription
or electronic.
• All prescriptions must be written in generic name without a brand name and in complete dosage
form and strength.
• No pharmacy items are dispensed without duly signed prescriptions. Doctors are the only
authorized to sign prescriptions.
• All prescriptions must have the date, name of patient, name and signature of the
prescribing physician. Prescriptions must be written legibly.
A. WRITTEN PRESCRIPTIONS
o For written prescriptions, the pharmacist checks the validity of the prescription
o Confirm the name of the patient since there might be a risk of mix up of prescriptions.
o Make sure there is a sufficient space for dispensing the medicines
o Select the correct medicines /items in the pharmacy and read the label on the container
(and/or package) before, during and after dispensing.
o Check the dispensed medicine and confirm that the medicine is what was prescribed
Center PROCEDURE
Revision: January 17, 2022 GOOD DISPENSING Effectivity date: Jan.23,2022
Review Date: December 12, 2021 PRACTICE Page No. 2 of 2
o Hand the dispensed medicine to the patient or patient’s S/O.

o Answer questions (if any) and give the patient appropriate answers.
o Keep the patient’s medication record.
B. ELECTRONIC PRESCRIPTION/ CHARGES

o The Patient/ Nurse/ Patient’s S/O comes to the pharmacy and says the patient’s name.
o The Pharmacy Staff confirms if there are this an order for the patient in the system
o The Staff prints and issues the charge slip.
o Hand the dispensed medicine to the patient or patient’s S/O.
o Answer questions (if any) and give the patient appropriate answers.
II. FLOOR STOCK SYSTEM

o Drug products are requested and stored in the nurse station in advance
o The Pharmacy Staff confirms if there are this an order for the patient in the system
o The Staff prints and issues the charge slip.
o The Nurses or Nursing Aides will pick up the medicines after the all drugs of the patients
have been dispensed.
o The nurse is responsible for the unit dose preparation, as well as administration and refill
of used drugs in the pharmacy.
V. END OF DOCUMENT

Center PROCEDURE
Revision: January 17, 2022 COLD CHAIN MANAGEMENT Effectivity date: Jan.23,2022
Review Date: December 12, 2021 COLD CHAIN DISPENSING Page No. 1 of 3
PEOCEDURE
I. OBJECTIVE
The procedure is established to provide a step-by-step guideline on the effective handling of cold
chain dispensing.
II. SCOPE
This procedure is implemented whenever a prescription calls for dispensing medicines which
requires a temperature of 2-8 ℃.
III. RESPONSIBILITY
The pharmacy staff follows the procedure to maintain the potency of the drug.
IV PROCESS DESCRIPTION
RECEIVING OF COLD CHAIN ITEMS
• Cooler boxes to be offloaded first and packed out immediately

• Contents of the cooler box and stock is to be packed into the refrigerator immediately and then
be reconciled with invoices.
COLD CHAIN DISPENSING
• Put and seal the prescribed medicine inside a small plastic bag.
• Put small cracks of ice on a separate plastic bag and place the sealed medicine inside the bag.
• Check the dispensed medicine and confirm that the medicine is what was prescribed
• Hand the dispensed medicine to the patient or patient’s S/O.
• Dispensed and explain to the patient the purpose of the procedure.
Review Date: December 12, COLD CHAIN MANAGEMENT Page No. 2 of 3

2021
COLD BOX
• Line the bottom and the sides of the cooler box with conditioned ice packs (i.e. ice packs that
have been left outside the freezer for a few minutes until the surface of the ice packs are moist)
• Place the temperature sensitive medicine on top of the ice pack. The medicine should not be in
direct contact in the ice pack. A container inside the cold box may be necessary if there is no
immediate protection of the medicine
• Conditioned ice packs are to be placed on top
• Close the lid and make sure it seals properly and that there are no cracks in the cooler box
• During stock usage the cooler box temperature is to be monitored when opened
CONTINGENCY PLAN IN CASE OF COLD CHAIN

EMERGENCY (MECHANICAL AND POWER FAILURE)
• In case of power failure, vaccines can be kept in the refrigerator

for 16 hours if the refrigerator has been turned on for at least eight (8)
hours prior to interruptions and if there are sufficient cold dogs in the
freezer. Monitor temperature hourly.
COLD BOXES:
• An insulated container with a tight-fitting insulated lid.

• Temperature is maintained by icepacks.
• Always validate the cold boxes prior to usage to determine the cold life and number of
ice packs to be used.
• Place temperature monitoring device to ensure that the required temperature is
maintained.
• Ice packs should not be taken from a freezer and placed directly in a cold box.
• Leave ice packs for a few minutes until water droplets appear on the surface before
putting them in the cold box.
Review Date: December 12, COLD CHAIN MANGEMENT Page No. 3 of 3

2021
CONTINGENCY PLAN IN CASE OF COLD CHAIN
EMERGENCY (MECHANICAL AND POWER FAILURE)
COLD BOXES:
USED FOR:
• Collection and transport of large quantities of vaccine at temperatures between 2℃ to

8℃. for a longer period of time.
• Storage of vaccine during maintenance periods – when cleaning or defrosting.
• Emergency storage of vaccine e.g. power failures.
V. END OF DOCUMENT

Revision: January 17, 2022 COLD CHAIN MANGEMENT Effectivity date: Jan.23,2022
Review Date: December 12, MONITORING BIOLOGICAL Page No. 1 of 2

2021 REFRIGERATOR
REFRIGERATOR
TYPES:
➢ Biological – equipped with thermometers
➢ Household – normally used for household purposes and should be installed with temperature
monitoring device.
THERMOMETER
➢ is an apparatus to measure temperature at any given moment.
➢ every piece of cold chain equipment must be fitted with a
thermometer to ensure that good storage conditions are maintained.
A. The household refrigerator at the pharmacy is installed with a thermometer
that shows the precise temperatures in the immediate area of the sensing bulb.
B. The thermometer is placed in the middle part of the main compartment of
the refrigerator.
C. The pharmacy staff on duty reads and note the temperature on the stock
card which serves as the temperature record sheet twice daily: in the morning and in the
afternoon.
D. The pharmacist conducts regular checking to cross check the data shown by the records.
E. All the completed temperature record sheets must be kept in file for future
reference.
The hospital pharmacy has a limited space on the pharmaceutical refrigerator as well as the
delivery room where the limited supplies of vaccine are stored, instead using a household
refrigerator in other areas other than the pharmacy.
Review Date: December 12, MONITORING BIOLOGICAL Page No. 2 of 2

2021 REFRIGERATOR
HOUSEHOLD REFRIGERATOR – normally used for household purposes and should be installed
with temperature monitoring device.
Points to consider:
• Must be placed in a well-ventilated area. Provide at least 20 cm. space from the wall.
• Must be regularly clean, defrost and observe safety engineering rules.
• Correct location of the refrigerator is important. Choose a location with good ventilation, air
circulation and away from direct heat and sunlight.
• Make sure nothing blocks the cover of the motor compartment.
• The better the condition of the refrigerator (cool, dry and good ventilation), the longer its shelf
life.
• Bottles of water should be placed at the bottom part to control the temperature of the refrigerator
• Food and drinking water must not be stored together with the drugs.
• Never store vaccines in the freezer (except for some vaccines), instead, use the freezer to store
the cold dogs for future use.
• Avoid storing vaccines in the door compartments. Vaccines should be placed in the center.
BIOLOGICAL REFRIGERATOR – a refrigerator intended for cold temperature drugs and vaccines.
Has a built-in thermometer
Points to consider:
• Must be placed in a well-ventilated area. Provide at least 20 cm. space from the wall.
• Must be calibrated once a year
• Clean filters every month
• Set the temperatures between 2-8 ℃.
V. END OF DOCUMENT

Review Date: December 12, MAINTENACE OF BIOLOGICAL Page No. 1 of 1

2021 REFRIGERATOR
DEFROSTING
Regular defrosting is essential as frost or ice buildup prevents efficient cooling of the refrigerator
compartment. Defrost when the frost layer reaches 5mm. thick. A thick layer of ice on the evaporator
surface hampers the work of the refrigerator. Defrosting is done by the pharmacy staff on duty as the
need arises.
PROPER PROCEDURE FOR DEFROSTING HOUSEHOLD REFRIGERATOR
• Remove medicines that require refrigerated storage and store them in a cold box with ice packs
or in another working refrigerator.
• Switch off the refrigerator and pull out the plug.
• Open the refrigerator and the freezer doors.
• Remove all ice packs from the freezer.
• Remove loose ice by hand only.
• Wipe the refrigerator, dry and clean thoroughly.
• Reconnect the power and turn the refrigerator on.
• Wait until the refrigerator is running again at correct temperature and then return the medicines.
PROPER PROCEDURE FOR CLEANING BIOLOGICAL REFRIGERATOR
• Remove medicines that require refrigerated storage and store them in a cold box with ice packs
or in another working refrigerator.
• Switch off the refrigerator and pull out the plug
• Open the refrigerator
• Clean with a moist, damp cloth. dry and clean thoroughly.
• Reconnect the power and turn the refrigerator on.
• Wait until the refrigerator is running again at correct temperature and then return the medicines.

Revision: December 2, 2010 COLD CHAIN MANGEMENT Effectivity date: January 2, 2011
Review Date: December 2,2010 STOCKING OF VACCINES Page No. 1 of 1
Limited supplies of vaccines are stored at the refrigerator inside the delivery room for direct
access during vaccination. Delivery room staffs were trained on the correct storage temperatures, the
proper handling conditions of the vaccines, what to do with the vaccines in an emergency situation. The
delivery room staffs were given copies of the policies and standard operating procedures. Presently, the
vaccines available at the delivery room are Hepatitis B Vaccine 10 mcg/5 ml Pedia, BCG Vaccine and
Tetanus Toxoid (Tetatox TT Vaccine 10.0 ml-20 doses IM). The Head-Midwife is over-all in charge at
the delivery room.

Revision: January 17, 2022 COLD CHAIN MANAGEMENT Effectivity date: January 23,
2022
TRANSFER OF COLD CHAIN
Review Date: December 12, DRUGS FROM PHARMACY TO Page No. 1 of 1
AMBULANCE AND VICE
2021
VERSA
From the Pharmacy:
• Validate the cold box to be used to determine the number of ice pack to be used.
• Wait for the ice pack to form water droplets before putting them in the cold box.
• Put the medicine together with a temperature monitoring device to ensure that the required
temperature is maintained.
• The ambulance nurse then picks up the cold box from the pharmacy to transfer in the ambulance.
From the Ambulance:
• The ambulance nurse will deliver the cold box to the pharmacy.
• The pharmacist will then inspect if the required temperature was maintained during transfer
using the temperature monitoring device.
• If the temperature required is maintained, the pharmacist will receive the medicine and transfer it
to the biological refrigerator.

Revision: December 2, 2010 Effectivity date: January 2, 2011
Review Date: December 2,2010 REPORTING ADVERSE DRUG Page No. 1 of 2

REACTION/EVENTS
I. OBJECTIVE
This procedure is established to provide a step-by-step guideline on the effective handling

of adverse drug reactions.
II. SCOPE
This procedure is implemented whenever there is an adverse drug reaction on any drug
administered to a patient.
III. RESPONSIBILITY
If the physician or nurse on duty assessed the reaction as ADR, the attending physician
shall fill up the ADR form and the nurse on duty will fill up the reports form. These reports are
then submitted to the Therapeutics Committee for final evaluation. The final report is
accomplished by the ADR committee and finally submitted to the Chief of Hospital and Food
and Drug Administration.
ADVERSE DRUG REACTION REPORT
1. When it happened.
2. Time it happened.
3. Dosage of drug when administered and negative reactions were seen.
4. Manifestation seen.
5. Regular dosage prescribed by the physician.
6. Total dosage given to patient.

Review Date: December 2,2010 REPORTING ADVERSE DRUG Page No. 2 of 2

REACTIONS/EVENTS
INVESTIGATION REPORT
1. Who administered the medicine?

2. What other medicines were given with it?
3. Type of medicine:
a) generic name
b) branded-brand name
4. Where the medicine was bought.
5. Other medications given to patient.
6. History of drug allergy of the patient
7. History of allergy within the family.
8. Contaminations:
a) syringes- disposable
b) intravenous fluids – how long since it was inserted.
c) diluent use – how long it is open
9. Use of an antiseptic
a) intravenous fluid
b) distilled water
10. Discoloration
a) outright dilution
b) prolong standing
11. Precipitate
a) cloudy
b) clear
12. Using the same brand – experienced the same problems which were unreported.
13. Is there previous report with the same generic or commercial brand?
14. Action of Therapeutic Committee.
a) Send to the Bureau of Food and Drugs (BFAD) for testing.
b) Inform drugstore/pharmacy where the medicine was bought.
15. Forms are available at the different stations and at the pharmacy.
V END OF DOCUMENT

Review Date: December 2,2010 PRODUCT COMPLAINT Page No. 1 of 2
I. OBJECTIVE
This procedure is established to provide a written guideline which outlines the

information required when lodging a complaint.
II. SCOPE
The procedure will be implemented whenever medicines are of inferior quality.
III. RESPONSIBILITY
The pharmacist facilitates the investigation process. The nurse on duty shall fill up the
product complaint form and is submitted to the pharmacy section. Then, the pharmacist collects
the forms and submits them to the Therapeutics & Supplies Committee for proper action.
IV. PROCESS DESCRIPTION.
I MEDICINES
➢ A complaint should be in writing.
➢ Address all complaints to the Chairperson of the Therapeutics and Supplies

Committee.
➢ Indicate the name, registration/lot number, batch number and the expiry date
of the medicine. Indicate the name of the manufacturer, supplier and contact details.
➢ State the detail of the complaint.
➢ Get and submit sample of the complained item for testing and analysis to the
Bureau of Food and Drugs, Alabang.
➢ Forms are available at the different stations and at the pharmacy.

Review Date: December 2,2010 PRODUCT COMPLAINT Page No. 2 of 2
V. END OF DOCUMENT

Review Date: December 2,2010 PRODUCT RECALL Page No. 1
I. OBJECTIVE
This procedure is established to provide a step-by-step guideline on the effective

handling of product recall.
II. SCOPE
This procedure shall be implemented whenever a recall is taken by a firm to

remove a product from the market or the Food and Drug Administration request.
III. RESPONSIBILITY
The head of the pharmacy shall be responsible for the implementation,

notification, follow up and documentation of the program because all requested item are directly
delivered to the pharmacy service.
• If the hospital pharmacy service receives a notice of product recall directly from the
manufacturer, or by the Bureau of Food and Drugs request or personally detects a product defect
or problem, the pharmacist must notify the concerned stations and provide them a copy of the
notice of recall.
• The pharmacist will collect all the items for recall. All recalled stocks should be stored at the
pharmacy service, placed in a box/bag and marked as RECALLED.
• The pharmacist will isolate the recalled stocks until they can be returned to the supplier for
replacement.
• Items returned to the pharmacy from other stations/departments will be replaced.
Documentation:
All documentation pertaining to the recalls, including notifications, replacement slips, and other
records must be kept in a file folder.
V. END OD DOCUMENT

Revision: December 2, 2010 Handling of Expired/Damaged/ Effectivity date: January 2, 2011
Review Date: December 2,2010 Rejected/Returned Stocks Page No. 1
I. OBJECTIVE
This procedure is established to provide a written guideline on the effective handling of

Expired/Damaged/Rejected/Returned Stocks.
II. SCOPE
This procedure shall be implemented whenever there are near expiring, damaged,
rejected/returned stocks.
III. RESPONSIBILITY
The pharmacist shall be responsible for the processing from informing the supplier to the
replacement of the stocks.
As stipulated in the bidding conditions, expiration date of a drug product, medical supplies
should be two (2) years from delivery date except in cases wherein the item delivered is needed
by the patients and can be consumed before the item expires based on its monthly consumption.
The pharmacist observes the first expiry-first out system in order to avoid expiry items to be
returned to suppliers.
In cases of near expiring stock or damaged stocks, the pharmacist informs the concerned
medical representative of the supplier before the expiration date. The medical representative will
schedule a date for the pickup. Such item is then returned, received and picked up by the medical
representative for replacement.
In cases wherein there are expired/damaged/defective stocks: such stocks are put in a box and
place at the designated area inside the storage room.
V. END OF DOCUMENT

Review Date: December 2,2010 DISPOSAL OF USED Page No. 1

EMPTY VIALS
I. OBJECTIVE
This procedure is established to provide a step-by-step guideline in the proper

disposal of empty used vial.
II. SCOPE
This procedure shall be implemented whenever there are empty used vials at the
different stations.
III. RESPONSIBILITY
It is the responsibility of the clinical worker to perform the procedure. The

pharmacist on duty oversees that the method is properly implemented.
• The different stations have a separate receptacle intended for the empty vials. The empty vials
are collected daily by the clinical worker on duty.
• The clinical worker on duty soaks the collected empty vials in water with bleach so that it will be
easier to strip off the labels as well as for disinfection. They are cleaned thoroughly. After they
are cleaned and dried, the clinical worker on duty gives them to the pharmacy section. The
pharmacy assistant on duty wrapped them individually. After packing, the empty vials are
weighed before they are given to the laundry worker on duty for autoclaving. He receives the
stocks and signs in the logbook after every transaction.
• After sterilization, the laundry worker on duty gives the sterilized vials directly to the supply
section where they are requested by concerned staffs and issued as specimen bottles.
V. END OF DOCUMENT

Review Date: December 12, DONATED PRODUCTS Page No. 1 of 1

2021
I. OBJECTIVE
This procedure is established to provide a written guideline on the proper way of
handling donated pharmaceutical products.
II. SCOPE
This procedure shall be implemented whenever there are donated products. The
pharmacist follows the guidelines set by the Food and Drug Administration and the policy of the
hospital.
III. RESPONSIBILITY
It is the responsibility of the pharmacist to perform the guidelines and policy properly.
• No pharmaceutical product intended for donation shall be accepted or distributed, unless it is

registered with the Bureau of Food and Drugs, in accordance with the provisions of R.A. 3720,
as amended and it’s implementing rules and regulation.
• Donated products must be in the Philippine National Formulary
• All donated items are given free of charge to patients. The pharmacy staff on duty records the
items issued on the logbook and stock cards for monitoring and inventory
• It is sealed and in the immediate or original container.
• It shall not be expiring within 6 months from time of donation.
• The pharmacy staff keeps all invoices and other pertinent papers in file.
V. END OF DOCUMENT


DANGEROUS DRUGS
Review Date: December 12, Page No. 1 of 3
AND THEIR CONTROL
2021
I. OBJECTIVE
This procedure is established to provide a written guideline on the proper way of standard
requirements and procedures for prescribing, dispensing, recording, reporting, storage, and
safekeeping.
II. SCOPE
This procedure shall be implemented whenever there are relevant regulations pertaining
to Dangerous Drugs
III. RESPONSIBILITY
It is the responsibility of the pharmacist to perform the guidelines and policy properly.
• LICENSING
• The Pharmacy shall acquire an S-3 retail distributor/ dispenser
• Annual fee for government run hospital pharmacies are exempted from paying corresponding
fees for license, by virtue for DDB Regulation No. 1 S. 2014 Article 3 Sec 36
• PROCUREMENT
• The Chief Pharmacist must apply for a Local Orfer permit as prescribed by PDEA prior to
procurement of Dangerous Drugs
• There should be a maximum entry for five (5) dangerous drug preparations in an application for
a single supplier
• Once approved, no alterations will be allowed
• An approved Local Order Permit comes in two (2) copies: 1 for the supplier and 1 for the
applicant
• REQUISITION OF DANGEROUS DRUGS FOR FLOOR STOCKING

• The Nurse/ Pharmacist in charge must legibly fill up a copy of Requisition sheet. The Complete
name of the issuing Pharmacist must be specified. Generic name, quantity, form, and strength of
the drug must be indicated and what specific station or room the

DANGEROUS DRUGS
AND THEIR CONTROL
2021
drug is required. It must be originally signed and dated by the nurse-in-charge and a PDEA-
licensed physician/
• The Requisition Sheet must be countersigned by the issuing pharmacist who will supply the
dangerous drug. Stock levels shall be periodically assessed by the pharmacist prior to ordering/
issuance to prevent overstocking of dangerous drugs
• The receiving nurse must indicate his/her name, signature, and date upon the receipt of the issued
stocks.
• An administration sheet will be provided together with the specific issued drugs to record every
drug used in the specific station.
• Photocopy the requisition sheet and put in a folder for dangerous drugs. For every station or
room, a folder with the compilation of photocopied requisition sheet shall be provided.
• Dangerous drug issuance from the pharmacy shall be recorder by the issuing pharmacist within
24 hours after the transaction was made.
• ADMINISTRATION
• Orders of Dangerous drugs upon administration by the nurse shall be recorded in the
Administration Sheet provided together with the drug with the required information:
a) Date and Time of Administration

b) Patient’s full name, Hospital Number, room/bed number
c) Name of prescribing physician, S2 license and signature
d) Name of Administering nurse and signature
e) Dose Administered
f) Balance of Dangerous drugs.
g) Remarks
• Recording of the Dangerous Drug Orders shall be accomplished by the nurse in charge within 24
hours after the drug has been administered.
• The nurse in charge must charge the dangerous drug via the computer system after writing in the
administration sheet.
• The pharmacist then issues the charge slip, and attached in the photocopied requisition sheet of
the specific drug administered.
• SEMI-ANNUAL REPORTING
• Summary of semi-annual report covering the period January to June or July to December,
certified true and correct and duly signed by the authorized pharmacist and noted by the

DANGEROUS DRUGS
AND THEIR CONTROL
2021
• head entity of the institution shall be submitted to PDEA-regional office 15 days following the
last day of June or December of each year
• Dangerous Drug Registers, Requisitions and documents shall be retained by the pharmacist for
two years after the last date of entry. Prescriptions shall be retained for one (1) year
• SAFEKEEPING AND STORAGE
• The Authorized pharmacist shall ensure that the safekeeping and handling of the dangerous
drugs are in accordance with the PDEA-prescribed guidelines on safekeeping, storage, use and
transport
V. END OF DOCUMENT


INVENTORY
Review Date: December 12, MANAGEMENT Page No. 1 of 1
2021
I. OBJECTIVE
This procedure is established to:
a) Identify slow, fast, and non-moving medicines
b) Check the accuracy of drug product quantity written on the census and the computer system
c) Reviewing balance of stocks in preparation of Purchase Request
II. SCOPE
The inventory of drugs will cover drugs
III. RESPONSIBILITY
It is the responsibility of the Chief pharmacist to assigned and consolidate the inventory
assigned to each staff
A. PHYSICAL INVENTORY
• Each staff will handle physical counting assigned to them by the Chief Pharmacist.
• Each staff will compare the physical count to the system count.
• The Chief pharmacist compiles the inventory done assigned to each staff
• The Chief pharmacist reconciles the discrepancies (if any)
• The Chief pharmacist prepares the final inventory report and signs it and the Chief of
hospital duly notes it.
• The report will then be forwarded to the Commission of Audit and Accounting Section, if
needed
B. DISPOSAL OF MEDICINES
• Segregate the spoiled, damage and expired drug products
• The Head of the Disposal Committee conducts inspection and recommends appropriate mode
of disposal
• The clinical worker impalements the approved mode of disposal
• V. END OF DOCUMENT

Review Date: December 12, RECORDS AND REPORTS Page No. 1 of 1

2021
I. OBJECTIVE
To produce better patient service and effective drug management
II. SCOPE
The records and report received and produced by the pharmacy which shall be the basis in the
preparation of reports to comply with government regulations, accreditation, and as support for legal
protection.
III. RESPONSIBILITY
It is the responsibility of the Pharmacy staff to safe-keep essential records and reports
with regards to pharmacy operations and services.
IV. REPORTS/ DOCUMENTS
A. Semi-Annual report of dispensed dangerous drugs
B. Quarterly Report of Electronic Drug Price Monitoring (EDPMS)
C. Monthly report on the issuances of drugs and medicines
D. Annual Procurement Plan
E. Individual Performance Commitment and Review (IPCR) and Department Performance
Commitment and Review (DPCR)
F. Pharmacist and Pharmacy Assistant Accomplishment Reports
G. Summary of number of prescriptions per day
H. Petty cash replenishment report
I. Hospital Pharmacy Standard Operating Procedures
J. Certificate of Product Registration
K. Sales Invoice and Delivery Receipts
L. Semi-Annual Inventory Report
M. S3 License and Renewal Documents
N. Utilization Reports
V. END OF DOCUMENT


DRESS CODE AND
Review Date: December 12, PERSONAL HYGIENE Page No. 1 of 1
2021
I. OBJECTIVE
Dress code is a set of guidelines to make it easy for employees to know what is appropriate to
wear to work
II. SCOPE
The guidelines will be applicable to all Pharmacy Staff
III. RESPONSIBILITY
The Chief Pharmacist is the one responsible to check the staff is compliant to the dress
code
IV. DESCRIPTION
DRESS CODE
• All staff must wear the identification card given and be worn and visible at all times when on
duty or in an official capacity representing the hospital
• Permanent employees may wear the uniforms given to them by the local government, if no
uniforms are given, they may wear the same color as prescribed per day. COS employees may
also comply with the prescribed color per day.
• Night duty employees may wear their old uniform, as long as it is still presentable.
• Staff working weekends may have a wash day. As long as the clothes are presentable and not
degrading.
PERSONAL HYGIENE
• Bathe regularly
• Hair should be clean, neat and tidy at all times
• Staff must wear clean, washed clothes
• Brush teeth after every meal
• Wash hands often
V. END OF DOCUMENT

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Rafael Lazatin Memorial Medical STANDARD OPERATING SOP No: 01

Review Date: December 12, 2021 HOSPITAL FORMULARY Page No. 1 of 1

IV. PROCESS DESCRIPTION

Prepared by: Reviewed by: Approved by:

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Revision: January 15, 2022 Effectivity date: January 23, 2022

This procedure is established to provide a step by step guideline in the procurement of

IV. PROCESS DESCRIPTION

1 – Purchase through Public Bidding

Revision: January 15, 2022 Effectivity date: January 23, 2022

In making the award, the following factors should be considered:

• Conformity with the specifications stated in the invitation to bid.

Revision: January 15, 2022 Effectivity date: January 23, 2022

2 – Purchase by Emergency Purchase

Revision: January 15, 2022 Effectivity date: January 23, 2022

3 –Purchase by Emergency Purchase through Petty Cash

Prepared by: Reviewed by: Approved by:

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Revision: January 15, 2022 Effectivity date: January 23, 2022

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Revision: January 16, 2022 Effectivity date: January 23, 2022

This procedure is established to provide a written guideline on the effective way of

B. Dangerous Drugs Storage

• Storage of controlled substances must be in a limited access cabinet.

Revision: January 16, 2022 Effectivity date: January 23, 2022

C. Storage of Biological products, vaccines and other drug products

• There should be sufficient biological refrigerators or improvised ordinary refrigerators to store

• Pharmacy Area – Less than 30°C

Prepared by: Reviewed by: Approved by:

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Review Date: December 12, 2021 CLEANING Page No. 1 of 2

The housekeeping personnel are responsible in implementing the procedure on garbage

• Make sure that exterior openings are closed appropriately

Review Date: December 12, 2021 CLEANING Page No. 2 of 2

II. SWEEPING AND MOPPING

Prepared by: Reviewed by: Approved by:

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

• The pharmacist on duty regularly counterchecks the floor stocks at the

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

Revision: January 17, 2022 Effectivity date: Jan.23,2022

Review Date: December 12, GOOD DISPENSING PRACTICE Page No. 1 of 2

The procedure is implemented when Licensed Physicians prescribed medicines.

IV. PROCESS DESCRIPTION

I. INDIVIDUAL PRESCRIPTION ORDER

Revision: January 17, 2022 GOOD DISPENSING Effectivity date: Jan.23,2022

Review Date: December 12, 2021 PRACTICE Page No. 2 of 2

o Hand the dispensed medicine to the patient or patient’s S/O.

B. ELECTRONIC PRESCRIPTION/ CHARGES

II. FLOOR STOCK SYSTEM

Prepared by: Reviewed by: Approved by:

MARIPER D. SANTOS, RPh, MPA JOHN B. MERCADO, MD FROILAN A. CANLAS, MD

• Cooler boxes to be offloaded first and packed out immediately

COLD CHAIN DISPENSING

Revision: January 17, 2022 Effectivity date: Jan.23,2022

Review Date: December 12, COLD CHAIN MANAGEMENT Page No. 2 of 3

CONTINGENCY PLAN IN CASE OF COLD CHAIN

• In case of power failure, vaccines can be kept in the refrigerator