Hello, Hope you're having a good day.
This page is a free sample showing what a hospital policy should look like. It can work at your place, you might need to modify it a little. The hospital here is HOSPITAL X. You might need to change that to your own institution name.
FORMULARY SYSTEM, UNAPPROVED INDICATION AND OUT OF STOCK MEDICATION
Formulary System: is a system describing the addition and deletion of drugs to/ from the approved medication list by Pharmacy and Therapeutic (P & T) Committee on the basis of safety, efficacy and cost effectiveness to be most advantageous in patient care.
Unapproved Indication: indication for which the drug is not licensed in FDA and still documented in respected reference as unapproved/ unlabeled or off labeled indication.
Out Of Stock Medication: is HOSPITAL X Formulary Drug that is currently not available in pharmacy and is needed within 24 working hours for life saving drugs and 48 working hours in case of non life saving drugs.
Life saving situation: is a condition where it is necessary to administer a particular life saving drug within 24 working hours in order to prevent what might result in a serious adverse patient event.
- The pharmacy department under the auspicious of the Pharmacy & Therapeutic (P & T) Committee will operate a closed formulary, which is reviewed annually by Pharmacy & Therapeutic (P & T) Committee for any addition, deletion and drug restriction.
- Formulary shall be updated on an ongoing basis and published every three years.
- Formulary shall be available in pharmacy department and all patient care areas.
- All health care team will be informed of changes in writing on timely basis for any drug restrictions formulary additions and deletions.
- Physicians shall not prescribe any medicine which is not included in the formulary (Non formulary drugs) and they shall consult and coordinate with pharmacy department before going thru non formulary drug process.
- The formulary drugs should be prescribed/ordered only for their approved indications. If the physician prescribed/ordered a formulary drug for unapproved indication, he/she should submit to the pharmacy with the medication evidence based documentation through a Request for Use of
Formulary Drug for an Unapproved Indication.
- The use of unapproved indication or off labeled drug is full responsibility of the treating physician.
- The use of unapproved indication or off labeled drug needs prior approval from the head of the department before using in particular patient.
- Clear justification and reference/s should be submitted along with request for single patient use of formulary drug for an unapproved indication form.
- The pharmacist on duty is responsible to follow the procedure in case of out of stock medication depends an urgency patient situation.
**start herePROCEDURE & RESPONSIBILITIES
Outpatient pharmacy supervisor and senior pharmacy clerk
CEO & Medical Director
Quality Management Department
Signed original is maintained in Manual & Indexing Office
inpatient Pharmacy Supervisor
outpatient Pharmacy Supervisor
Chief Executive Officer (CEO)