CHAPTER 4:

MEDICATION MANAGEMENT

Abcede.Azurin.Bautista.Borromeo.Chica.Cinconiegue
2C-PH

Key Terms and Definitions

Closed formulary: limits access of a practitioner to some medications
Drug formulary: continually updated list of medications and related
information
Drug monograph: written, unbiased evaluation of a specific medication
Drug therapy guidelines: describes the indications, dosage regimens,
duration of therapy, mode of administration, monitoring parameters and special
considerations for use of a specific medication
Drug use evaluation (DUE): used to assess the appropriateness of drug
therapy
Diagnosis-related DUE: completed on patients with specific disease state or diagnosis
Prescriber-related DUE: completed on patients managed by specific physician or physician
group
Drug-specific DUE: completed on a drug

FOCUS-PDSA: performance improvement model used by hospitals and healthsystems

Formulary restriction: act of limiting use of specific formulary medications
Formulary system: process whereby a health care organization establishes
policies on the use of drug products and therapies

Key Terms and Definitions

Health-system board: governs the affairs of hospital or health-system

Medical executive committee: has primary authority for activities related to self
governance and for performance improvement of professional services
Medication use review: focuses on evaluating and improving medication-use
processes
Nonformulary agent: not part of drug formulary
Open formulary: no limitation to access to a medication by practitioner
Outcome assessment: systematic process of evaluating the appropriateness, safety,
and efficacy of medication
Pop-ups: appears on computer monitor when specific actions are taken
Stop orders: physician orders that are automatically terminated
Therapeutic class review: evaluation of group of medications with an established
therapeutic class
Therapeutic equivalent: drug products with different chemical structures but of same
pharmacologic or therapeutic class and usually having similar therapeutic effects and
adverse reaction
Therapeutic interchange: authorized exchange of therapeutic alternatives

What is Medication Use

Management?
This describes the process used to assure the safe and
effective use of drugs in a cost conscious manner
Key to medication management system environment is the
formulary system.

The Formulary System

This is a mechanism for ongoing assessment of
medications that are available for use
Managed by a committee of experts which includes
pharmacists and physicians.

The Drug Formulary

This refers to a continually updated list of medication
representing the clinical judgment of health care experts.
List of medications routinely stocked by the health care system
Developed in the hospitals in the 1950s as a management tool
Initially used to ensure adequate drug supply for physicians
Key purpose was to discourage the use of marginally effective
drugs and treatment
Has evolved beyond a simple list of medications
Now an element of system that includes medication use policies, P&T
committee, medication use evaluation, and formulary management.

Importance of Formularies
It methodically evaluates medications on an ongoing basis
for inclusion or exclusion
It establishes guidelines for optimal medication use
It develops policies and procedures for prescribing,
dispensing and administering medications

Advantages and
Disadvantages of a Formulary
System
Advantages:
Provides systematic method to review scientific evidence on
clinical effectiveness and cost effectiveness in drug selection
decision
Potentially improves health outcomes while reducing cost

Disadvantages:
An overly restricted formulary system may potentially reduce the
quality of care by limiting access to clinically indicated medications

Therapeutics Committee
(P&T)
Manages the formulary system
Has oversight of medication management in the health
system
Generally a policy recommending body to the medical staff
through the medical executive committee.
A group of the hospital medical staff in charge of
institutional governance and performance.

Has reported directly to a non-medical staff advisory

committee of hospital and community members called a
health-system board.

Therapeutics Committee
(P&T)
Meetings should occur at least four to six times per year.
Generally, monthly meetings are needed to keep the
meeting time to 60-90 minutes.
Subcommittees or task forces have been established to
facilitate meeting efficiency.
Medication safety
Drug review panels
Medication use review

Medication Safety Task Force

Charged with review of adverse drug events and medication
errors, their trending and development of plans for
prevention of future events.

Drug Review Panels

Focused on a particular specialty such as cardiology or
infectious disease and review drug products and guidelines
in there area of specialty.

Medication Use Review Task Force

Monitor one or more medications use reviews, evaluate the data
and development plans to optimize specific drug use.

Therapeutics Committee
(P&T)

It is important to establish rules for a quorum to make

certain that the key stakeholders are represented at
meetings.

Establish a minimum number of members that must be

present to conduct a meeting
Establish a minimum number of member types that must be
present to conduct a meeting.
E.g. a committee with 15 members might be required to have at least
five members present to which two must be physician and one must
be a pharmacist before a quorum has been established.

Pharmacy and
Therapeutics Committee
(P&T)
Committee Membership
Should include pharmacists, nurses, physicians,
administrators, risk or quality improvement
managers, and others as appropriate.
It should include nonphysician members because the
medication management is a multidisciplinary process.

Therapeutics Committee
(P&T)
RESPONSIBILITIES:
The committee performs the following functions:
Establishes and maintains the formulary system.
Selects medications for formulary inclusion by considering
the following:

Relative clinical
Quality of life
Safety
Pharmacoeconomic outcomes

Therapeutics Committee
(P&T)
RESPONSIBILITIES:
Evaluates medication use and related outcomes.
Prevents and monitors adverse drug reactions and medication
errors.
Evaluates or develops and promotes use of drug therapy
guidelines.
Develops policies and procedures for handling medications
Educates health professionals to the optimal use of
medications.

Formulary System
Maintenance
The committee develops a list of medications for use in the
organization.
May also develop guidelines for the optimal use of the
medications and/or for specific disease management.
They review the medication list and guidelines on a regular
basis.

Medication Selection and Review

The committee should have established methods for
medication selection and review.
A written medication review is prepared from available
literature.
The review should be unbiased.
Meeting participants should be required to discuss any
conflict of interests prior to discussion of the drug or drug
class.

Medication Selection and Review

Medication Selection Criteria:
Is it a duplication of an existing formulary agent? If so, is it
more effective? Safer? Less costly?
How should it be used?
When should it be used?
Who should use it?
Are there any other special concerns?

Medication Selection and Review

Barriers to Optimal Formulary Decisions:
Physician experience with the drug under consideration
Physician preference for other agents
Detailing by pharmaceutical company representatives
Unpublished or anecdotal studies and reports

Medication Use Evaluation

Method for evaluating and improving medication-use
process with the goal of optimal patient outcomes.
Medications may be considered for review based on the
following:

Use
Safety
Cost
Combination of factors

Medication Use Evaluation

Foundation of the Medication-Use Process:
Establishment of specific criteria for use
Review for compliance to the criteria
Routine review of the data
*Key to the process is timely data to review, action plan
development, and follow-up.

Medication Safety Evaluation

Medication safety is evaluated through adverse drug
reaction reports and medication error reports.
LOCAL: from the health system
GLOBAL: from literature or press releases

The impact of such reports should be considered relative

to the health-system population, resources, and alternatives.
Such reports should be used in considering whether a drug
should be added to the formulary, retained on the
formulary, or deleted from the formulary.

Drug Therapy Guidelines

Listing of the indications, dosage regimens, duration of
therapy, mode(s) of administration, monitoring parameters
and special considerations for use of a specific medication
or medication class.
They are often put into practice via a pre-printed physician
order sheet placed in the patient chart or computerized
order set.
The development of the guidelines is often the result of a
medication use review or medication safety evaluation.

Drug Therapy Guidelines

The development and implementation of these guidelines
may foster the safe, efficacious and cost effective use of
selected drug products.
Just as important is a method for routine review of the
guidelines to assure they are current.

Policy and Procedure

Development
The P&T committee is responsible for the medication use
in the hospital. This includes the development of
guidelines on historically pharmacy related topics of
medication procurement, selection and distribution.
They are also responsible for the medication
administration process.
determining what medications are administered in specific
locations for the hospital (intensive care unit)
Under specific conditions (chemotherapy certified nurse)

Policy and Procedure

Development
They define the formulary management process,
specifically, guidelines for the evaluation of medications
by the P&T committee, frequency of such review,
maintenance of the medication list, etc.

Education
The P&T committee must communicate its actions to healthsystem staff and physicians.
NEWSLETTER:
Often employed to communicate different decisions of the
committee.
May also include clinical information on drugs added to the
formulary, drug therapy guidelines developed, and medication
safety information available.

Education
NEWSLETTER:
Its success may be limited by the format and content.
It should be visually pleasing, easy to follow and succinct.
It should be limited to two to four pages in length.
The audience is generally broad and includes physicians,
nurses, pharmacists, and other health-care professionals.

Education

Education
Other methods to communicate and educate others to P&T
committee actions:
Presentation at medical staff department meetings
Nursing unit staff meetings
Pharmacy staff meetings
Electronic messaging (e.g. through email or the health-system
website)

Regulatory and Accrediting

Bodies
May require a P&T committee and define its membership
and responsibilities
REGULATORY BODIES
State Department of
Health
Board of Pharmacy
Varies by state

ACCREDITING BODIES
The Joint Commission
American Osteopathic
Association (AOA)
Commission on Accreditation
of Rehabilitation Facilities
(CARF)
Facility type will define the
accrediting body

Regulatory and Accrediting

Bodies
Each has a slightly different interpretation of the term
formulary.
Regulations and accreditation standards are dynamic and
require vigilance by the pharmacy to assure compliance.

Pharmacist Role
Pharmacists are essential to the formulary management
process.
They will often guide the P&T committee activities to assure
optimal medication management.

Pharmacist Role
Pharmacist responsibilities may include the following:
Establish P&T committee meeting agenda.
Analyse and disseminate scientific, clinical and health economic
information
Conduct drug use evaluation and analyse data.
Record and archive P&T committee actions.
Follow-up with research when necessary.
Communicate P&T committee decisions to other health-care
professionals.

Formulary
Management
patient care
medication efficacy and safety

financial implications
cost of the drug
costs associated with stocking the medication (shelf
space, drug outdates, and handling)

OPEN FORMULARY
- no limitation to access to a medication
- Generally large

CLOSED FORMULARY
- limited list of medications
- may limit drugs to specific physicians, patient care areas, or
disease states via formulary restrictions

FORMULARY RESTRICTIONS
*do not necessarily translate to optimal medication
management
---Formulary restrictions often have
unintended consequences(e.g. Antibiotic
Resistance)

 Drug product selection should be based on individual

chemical entities

Approved Drug Products with Therapeutic

Equivalence Evaluation
- Orange Book
- where the list of the generic equivalents is
found

Therapeutic Equivalents
- drug products with different chemical structure but are
of the same pharmacologic and/or therapeutic class
- expected to have similar therapeutic effects
effects

and adverse

Therapeutic Interchange
- authorized exchange of therapeutic alternatives in
accordance with previously established and approved
written guideline

Examples of therapeutic
interchanges

Guidelines for generic

substitution and therapeutic
interchange
Pharmacist is responsible for selecting generically
equivalent products in concert with FDA regulations
Prescribers may specify a specific brand if clinically
justified

decision should be based on pharmacologic

and/or therapeutic considerations relative to the
patient.
The P&T committee determines therapeutic equivalents
and how they are processed

Pharmacist is responsible
for the:
Quality
Quantity
Source of all medications
Biologicals and pharmaceutical preparations used in
the diagnosis and treatment of patients

FORMULARY MAINTENANCE
ongoing process of assuring relative safety and efficacy of
agents available for use in the health-system

PROCESS:
New product evaluation
Therapeutic class review
Formulary changes (rationale for retaining or deleting an
agent from the formulary)
Nonformulary drug use review

The evaluations of an agent should consider:

- indications for use
- pharmacokinetics
- safety
- cost

Considerations to:
- drug storage
- mode of administration
- special considerations
- drug dispensing issues

NEW
PRODUCT
EVALUATION

Standard elements include

the following:

Generic name

Trade name

Therapeutic or pharmacologic class

Pharmacology

Pharmacokinetics

Indications for use

Clinical study

Standard elements include the

following:

Adverse effects/warnings

Drug interactions

Dosage range

Dosage forms and cost

Summary

Recommendation

References

The objective is to have the optimal agents within a

therapeutic class in terms of efficacy, safety, and cost.
The end result of a therapeutic class review may be
formulary modifications, implementation of a drug use
review or the development of therapeutic guidelines.

THERAPEUTIC
CLASS
REVIEW

FORMULARY CHANGES

A process to continually update the formulary involves the

submission of a request for formulary addition or deletion
from the pharmacy or medical staff. Requests generally
require specific information.
- agent to be considered for addition/deletion
- rationale for request
- alternative agents currently on the formulary

NONFORMULARY DRUG REVIEW

Nonformulary agent

-A medication that is not part of the drug formulary. This

may be due to the medication not being considered for
formulary addition or the medication being considered but
the P&T committee choosing not to add it.

Drug use evaluation (DUE)

- a systematic process used to assess the appropriateness of
drug therapy by engaging in the evaluation of data on drug use
in a given health care environment against predetermined
criteria and standards

Medication use evaluation (MUE)

-encompasses the goals and objectives of DUE in its broadest
application, with an emphasis on improving patient outcomes
***Use of MUE rather than DUE emphasizes the need for a more
multifaceted approach to improving medication use.

 First established in the 1980s

An ongoing, structured, organized approach to ensure that drugs
are used appropriately
outcome assessment has been used to describe such programs
The desired endpoint is safe, efficacious drug therapy

DRUG USE and

MEDICATION USE
EVALUATION

***Medication use evaluation programs should be

incorporated into the overall hospital performance
improvement process

FOCUS-PDCA

 Find process to improve

Organize a team that knows the process
Clarify current knowledge of the process
Understand causes of process variation
Select process improvement
Plan
Do
Check (or Study)
Act

FOCUS-PDCA

 Pharmacists can take a leadership role in designing the

drug use evaluation programs.
The program should measure and compare the outcomes
of patients who received drug therapy in concert with
approved criteria versus those that did not.
Selection of agents for drug use evaluation programs
should be based on whether a drug is high-use, high-cost,
or high-risk.
Pharmacists, working with key physicians, develop criteria
for drug use evaluation.

Medication Use Criteria

Diagnosis-related DUE criteria
identify indications for which select drug(s) may be
appropriate for a given disease state

Prescribers-related DUE criteria

identify specific physicians whom the P&T committee
has determined may use certain drugs

Drug-specific DUE criteria

focus on specific aspects of a select drug such as the
dose or dosing frequency

Develop Criteria for Drug Use

Evaluation
The criteria should be focused and limited.
Select three to five criteria to evaluate that are meaningful and
simple to collect.
If possible, data should be collected during the patient visit
(concurrent) rather than retrospectively (chart review).
The criteria should also include a number of patients to be
reviewed and the time period.
The drug use evaluation criteria are presented to the P&T
committee for their review and endorsement prior to commencing
data collection.

Develop Criteria for Drug Use

Evaluation
Technology may be used to collect or screen data.
Use of information systems to identify patients for review and collate the data
will facilitate the process.
Handheld computers or personal data assistants (PDAs) may be useful in the
data collection process.

Once the data has been collected, it should be compiled for review.
The use of trend graphs or control charts are helpful in identifying
opportunities for improvement.

Once the data is collated, it may be beneficial to form a task force to

develop an action plan and criteria for ongoing monitoring
The action plan may include development of drug use guidelines, pre-printed
orders, medication order entry rules, professional staff education, formulary
changes, or a combination of these actions

Develop Criteria for Drug Use

Evaluation
The drug use evaluation results and action plan are presented to
the P&T committee for consideration.
A single drug use evaluation should not continue indefinitely.
Once the desired endpoint has been achieved, an ongoing review
may be discontinued or conducted less frequently

Pharmacy and
Therapeutics
Committee
The policy should address the committee membership,
operation, and responsibilities

Dispensing, and
Administration
Writing medication orders or prescriptions defines
practitioners that may write medication orders or prescriptions
in concert with state and federal regulations. This or related
policies may also include the format for order writing and
unacceptable abbreviations.
Verbal orders defines who may accept a verbal order and the
transcription process of such an order. This policy should
address the reading back of the order to confirm its accuracy

Dispensing, and
Administration
Stop orders defines the orders that are automatically
terminated, how the prescriber is notified, if appropriate,
and the method for their reinstatement
Investigational drug orders defines how investigational
drugs are managed in the health care system. This policy
should include the review process as well as the method
for prescribing, dispensing, administering, and monitoring
investigational agents

Dispensing, and
Administration
Controlled substances defines the flow of controlled
substances through the health care system. This policy should
include approved prescribers, the ordering process from the
pharmacy and the vendor, the distribution and tracking of use,
discrepancy tracking and follow-up, and management of
diversion.
Generic and therapeutic substitution defines how a drug is
selected for generic substitution and therapeutic equivalents
approved by the P&T committee. It should describe how an
alternative agent may be prescribed if deemed medically
necessary.

Dispensing, and
Administration
Self-administration of medications defines the conditions
and process for the administration of medication by the patient
in the hospital setting.
Medication samples defines the conditions and process for
the use of medication samples in the hospital or clinic setting
Floor stock defines the criteria for selecting agents for floor
stock, process for modifying the stock, and the regular review of
the stock by the P&T committee.
Definition of order interpretation defines the meaning of
specific types of orders including sliding scale orders, range
orders, as needed orders, tapering orders, and titrating orders.

Dispensing, and
Administration
Medication administration times defines specific medication
administration times and rules for interpretation. This may include
the definition of stat and related terminology.
Adverse drug reactions defines an adverse drug reaction, the
reporting process, and monitoring methods.
Medication errors defines a medication error, the reporting
process, and monitoring methods.
Other include pharmaceutical representatives, pharmacy hours
of service, emergency medications, and medication delivery
devices.

It should provide:
information on the medications approved for use
basic therapeutic information about each item
information on medication use policies and procedures
special information about medications such as dosing
guidelines

PUBLISHED
FORMULARY

MEDICATION LIST

It is the key element of the published formulary.

It includes both entries for each medication and indexes to

facilitate use.
May be arranged alphabetically by generic name and trade name,
therapeutic class, or a combination.
The list should include one or more indexes
One type of index is by using generic name or both generic
and trade name.
The second type is the therapeutic index which arranges
drugs generically by therapeutic or pharmacological class
(useful for prescribers not familiar with the formulary of a
health-system and desires to prescribe a certain type of drug).

The following should be included in each drug entry:

generic name of primary active ingredient
trade or synonym name that is commonly used
dosage form, strength, and size stocked by the pharmacy
active ingredients (formulation) for combination products
These are additional information that can be added:
DEA schedule (C-II through C-V)
special precautions
pediatric or adult dosage ranges
Cost information

MEDICATION USE POLICY

AND PROCEDURES
Inclusion of information on the prescribing, dispensing, and
administration of medications for a quick reference.
Policies for inclusion are the
formulary policy
P&T committee policy
organizational regulations regarding medication use
Information on pharmacy operating procedures may be beneficial
(hours of services, prescription policies, medication distribution
procedures, contact information, and other pharmacy services).

MEDICATION USE GUIDELINES

It should detail guidelines which are approved or endorsed by
the P&T committee.
Such guidelines may include pre-printed orders and clinical
pathways that have been developed.
SOME EXAMPLES:
Antibiotic use guidelines
Antibiotic use in surgical prophylaxis
Weight-based heparin orders
ICU sedation guidelines

SPECIAL INFORMATION
The information is health-system specific
Should be tailored to the needs of the professional and medical
staff

SOME EXAMPLES OF TOPICS TO INCLUDE:

o Nutritional products approved for use
o Equivalent dosage tablets (e.g., pain medications)
o Antidote list
o Serum drug levels
o Antibiograms

PUBLISHING THE
FORMULARY
Must be published regularly
Medication list should be readily available to all personnel
involved
Electronic versions may be preferable
Copies should be made available where medications are
prescribed, dispensed, and administered
Printed formularies are often revised and printed annually
A method for updating the formulary between editions should
be established

THANK YOU!!
No Medicine cures
what Happiness
cannot.
-Gabriel Garcia Marquez