TPH Therapheutics

Provincial Government of Tarlac
Provincial Health Office
Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com
Document Name :
TPH PHARMACY AND

THERAPEUTICS COMMITTEE
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 :
TPH PHARMACY & THERAPHEUTICS

COMMITTEE
TPH PHARMACY & THERAPHEUTICS
COMMITTEE
TPH PHARMACY & THERAPHEUTICS COMMITTEE
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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
TABLE OF CONTENTS
NO.
PARTICULARS
1. PHARMACY AND THERAPEUTICS COMMITTEE

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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
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.
3. ORGANIZATION AND OPERATION OF PTC

(1)
The PTC should be composed of at least three physicians, a pharmacist and

representatives of the nursing staff. Committee members are appointed by a
governing unit or elected officials of the organized medical staff. The hospital
administrator or his/her representative should be an ex officio member of the
committee.
(2)
A chairman from among the three physician representatives should be appointed. A

pharmacist usually is designated as secretary.
(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)
An agenda and supplementary materials (including minutes of the previous

meeting) should be prepared by the secretary and submitted to the committee
members in sufficient time before the meeting for them to properly review the
material.
(6)
Minutes of the committee meetings should be prepared by the secretary and

maintained in the permanent records of the hospital.
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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
(7)
Recommendations of the committee shall be presented to the medical staff or its

appropriate committee for adoption or recommendation.
(8)
Liaison with other hospital committee concerned with drug use (e.g. infection
control, medical audit) shall be maintained.
4. FUNCTIONS AND SCOPE OF PTC

(1)
To serve in an evaluative, educational, and advisory capacity to the medical staff

and organizational administration in all matters pertaining to the use of drugs.
(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)
To establish or plan suitable educational programs for the organization's

professional staff on matters related to drug use.
(6)
To participate in quality assurance activities related to distribution, administration,

and use of medications.
(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)
To advise the pharmacy department in the implementation of effective drug

distribution and control procedures.
(10) To disseminate information on its actions and approved recommendations to all

organizational health care staff.
5. POLICIES OF THE COMMITTEE
5.1
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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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
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
Drug Approved on a Conditional Trial Period

A drug approved by the BFAD for general use but which the Committee will
evaluate for a 6 to 12 months period before final consideration. During that
period, the drug may be prescribed by all members of the attending and
house staff.
5.2.3
Specialized Formulary Drug

An BFAD approved drug which is recommended for use in specialized
patient care. The drug may be placed in this category by the proposer or the
Committee and either may designate those persons authorized to prescribed
the Specialized Formulary Drug.
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)
An old or approved drug proposed for a new use

A new combination of 2 or more old drugs.
A combination of old drugs in new proportions
A new dosage form or method of administration.
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
Drug Recall may emanate from manufacturers, regulatory agencies, or the

Pharmacy Department, and may be of a general nature or a specific recall for one or
more lot numbers. Once the recall notice is received, the drugs will be removed and
replaced; and this information will be sent to staff and pertinent hospital
departments.
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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
5.7
In Patient Prescribing
5.7.1
Routine Drug Orders

A physician's medication order written on in-patient order form is deemed a
legal prescription. A legible copy of the medication order must be forwarded
to the Pharmacy. Orders written by medical students must be counter-signed
by a member of the medical staff. Quantities of drugs to be dispensed need
not be specified since the pharmacist will determine the optimum amounts
in keeping with greatest economy to the patients and efficiency in handling
and storage by the nursing and pharmacy staff.
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
Total Parenteral Nutrition (TPN)

TPN has been designed to serve as a nutritional infusion providing essential
amino acids, carbohydrates, and electrolytes for patients incapable of
ingesting, digesting, or absorbing food substances given by mouth. Since a
standard hyperalimentation solution always be prepared extemporaneously,
the pharmacy department shall be responsible for the preparation of these
solutions.
5.7.3.1
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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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Only electrolytes and vitamins may be added to

hyperalimentation solution
5.7.4
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
Automatic Stop Orders

Applies to instances when the physician did not specify the exact number of
doses or duration of therapy (open ended drug order). The automatic stop
order policy serves as a protection against indiscriminate and indefinite open
ended drug orders that can be harmful to the patient and at the same time
ensures continuous therapy if so desired by the physician.
5.7.5.1
Automatic Stop Orders requirements for medications are:

a) 24 hours for controlled drugs
b) 7 days for all other drugs
5.7.5.2
PRN and standing orders for all medications except Controlled

drugs expire at 10:00AM of the following Tuesday. All orders shall
be renewed between the hours of 4:00PM Monday and 10:00AM
Tuesday. Orders which are written on Monday become effective at
10:00AM Tuesday.
5.8
A new medication order must be written by the physician if a change is wanted in

route of administration or in dosage.
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.
5.10 Emergency (STAT) Orders

Bonafide emergency orders should be rare and in most cases obtained from the
nursing station emergency drug supplies. When necessary, these orders should be
transmitted in writing on the Pharmacy copy of the in-patient order form. This
procedure prevents unnecessary delay and confusion which results from hurried
verbal transmission orders. If it is necessary to phone the pharmacy for emergency
drugs, calls should be placed either by the physician or the nurse in order to avoid
delay and error.
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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
5.11 Emergency Kit or Stat Boxes

Contains drugs and supplies which is readily available in case of emergencies. The
medications and related accessories are standardized and approved by the medical
staff through the Pharmacy and Therapeutics Committee.
6. THE HOSPITAL FORMULARY
The need for hospital formularies becomes increasingly great because of:
(1) the increasing number of new drugs being marketed,
(2) the increasing influence of biased advertising and unscientific scientific drug
literature,
(3) the increasing complexity of untoward effects of the newer more potent drugs,
(4) the highly competitive marketing practices of the pharmaceutical industry; and
(5) the public's interest in seeing that the health professions are continuously providing
the best possible care at the lowest possible cost.
In the interest of better patient care, the institution should have a program of objective
evaluation, selection, and use of medicinal agents in the facility. This program is the
basics of appropriate, economical drug therapy. The formulary concept is a method for
providing such a program and has been utilized as such for many years.
6.1
DEFINITION OF FORMULARY AND FORMULARY SYSTEM

Formulary System is a method whereby the medical staff of an institution, working
through the PTC evaluates, appraises and selects from among the numerous
available drug entities and drug products those that are considered most useful in
patient care. Only those so selected are routinely available from the pharmacy. The
formulary system is thus an important tool for assuring the quality of drug use and
controlling its costs.
Formulary is a continually revised compilation of pharmaceuticals (plus important
auxiliary information) that reflects the current clinical judgment of the medical
staff.
7. FORMULARY CONTENT AND ORGANIZATION

7.1
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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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
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
PART I: Information of Hospital Policies and Procedures Concerning

Drugs
The material to be included in this section may vary from hospital to
hospital. Generally, the following items may be included:
(1) Categories of drugs,
(2) Brief description of the PTC,
(3) Hospital regulation governing the prescribing, dispensing and
administration of drugs,
(4) Pharmacy operating procedures, and
(5) information on using the formulary.
7.2.2
PART II: Drug Product Listing

This section is the heart of the formulary and consists one or more
descriptive entries for each formulary item plus one or more indexes to
facilitate the use of the formulary. Formulary item entries are entries that can
be arranged in several ways:
(1) alphabetically generic name with entries for synonyms and brand names
containing only a see generic name notation,
(2) alphabetically within the therapeutic class,
(3) a combination of the two systems whereby the bulk of the drug are
contained (alphabetically) in a general section which is supplemented
by several special sections such as ophthalmic / otic drugs,
dermatological and diagnostic agents.
7.2.3
PART III: Special Information

Example of items found in the special information section of hospital
formularies are: list of hospital-approved abbreviations, poison antidote
charts, etc.
8. SELECTION OF GUIDING PRINCIPLES FOR ADMISSION OR DELETION OF

DRUGS
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Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
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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TPH Therapheutics

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Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

TPH PHARMACY AND

TPH PHARMACY & THERAPHEUTICS

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

1. PHARMACY AND THERAPEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

3. ORGANIZATION AND OPERATION OF PTC

The PTC should be composed of at least three physicians, a pharmacist and

A chairman from among the three physician representatives should be appointed. A

An agenda and supplementary materials (including minutes of the previous

Minutes of the committee meetings should be prepared by the secretary and

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

Recommendations of the committee shall be presented to the medical staff or its

4. FUNCTIONS AND SCOPE OF PTC

To serve in an evaluative, educational, and advisory capacity to the medical staff

To establish or plan suitable educational programs for the organization's

To participate in quality assurance activities related to distribution, administration,

To advise the pharmacy department in the implementation of effective drug

(10) To disseminate information on its actions and approved recommendations to all

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

Drug Approved on a Conditional Trial Period

Specialized Formulary Drug

An old or approved drug proposed for a new use

Drug Recall may emanate from manufacturers, regulatory agencies, or the

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

Routine Drug Orders

Total Parenteral Nutrition (TPN)

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

Only electrolytes and vitamins may be added to

Automatic Stop Orders

Automatic Stop Orders requirements for medications are:

PRN and standing orders for all medications except Controlled

A new medication order must be written by the physician if a change is wanted in

5.10 Emergency (STAT) Orders

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

5.11 Emergency Kit or Stat Boxes

DEFINITION OF FORMULARY AND FORMULARY SYSTEM

7. FORMULARY CONTENT AND ORGANIZATION

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital

PART I: Information of Hospital Policies and Procedures Concerning

PART II: Drug Product Listing

PART III: Special Information

8. SELECTION OF GUIDING PRINCIPLES FOR ADMISSION OR DELETION OF

TPH PHARMACY & THERAPHEUTICS COMMITTEE

Provincial Government of Tarlac

Tarlac Provincial Hospital