Chapter 4: Medication Management
multidisciplinary process
Key Terms & Definitions
Drug monograph written, unbiased
evaluation of a specific medication ; drug
name, therapeutic class, pharmacology,
indications, clinical trials, ADE, drug
interactions
The Formulary System
ongoing process whereby a HCO establishes
policies on the use of drug products & therapies
Drug Formulary continually updated
list of medications & related info,
representing the clinical judgment of
RPh, physicians & other experts in
treatment of disease & promotion of
health
List of medications routinely stocked
developed in the 1950s as a selection & review
management tool ; discourage the use of
marginally effective drugs & treatments
Element of a system that includes med.
Use policies, PT&C, med use evaluation,
& formulary management
Advantage: provides a systematic
method to review scientific evidence on
clinical effectiveness in drug selection
decision
Disadvantage: overly restrictive
formulary, limited access to medications
Pharmacy & Therapeutics Committee
Organization
Committee is a policy recommending
body to the medical staff
Medical executive committee grp of the
hospital medical staff in charge of
institutional governance & performance ;
w/ primary authority for activities related
to self governance & performance
improvement
Health-system board - non-medical staff
advisory committee of hospital members
& community members that governs the
affairs of hospital
Subcommittees / task forces facilitate
meeting efficiency
o Medication safety review of
adverse drug events & med errors
o Medication use review
performance-improvement
method that focuses on
evaluating & improving med-use
processes for optimal pt outcomes
o Drug review panels review drug
in an area of specialty ( cardiology
) drugs
Committee Membership
RPh, nurses, physicians, administrators,
risk / quality improvement managers
Medication management is a
Responsibilities
Establish & maintain the formulary
system
Select medications for inclusion by
considering clinical, quality of life, safety
& pharmacoeconomic outcomes
Evaluates med use outcomes
Monitors adverse drug reactions
Develops policies & procedures for
handling medications
Educate health professionals
Formulary System Maintenance
Review medication list & guidelines on a
regular basis
Medication Selection and Review
Established methods for medication
Med.selection criteria: med efficacy,
safety & cost
Barriers to optimal formulary decisions
o Physician experience w/ drug &
preference
o Detailing by pharmaceutical
company representatives
o Unpublished / anecdotal studies
Medication Use Evaluation ( MUE )
Method for evaluating & improving med-
use process w/ the goal of optimal
patient outcomes
Foundation of med-use process
o Establish a specific criteria for use
o Review for compliance ; Routine
review of data
Key to process timely data to review,
action plan development , follow up
Medication Safety Evaluation
Evaluated through adverse drug reaction
reports & medication error reports
Drug Therapy Guidelines
Listing of the indications, dosage
regimens, duration of therapy, mode of
administration, monitoring parameters &
special preacautions
Developed w/ the oversight of
practitioners w/ expertise in the
management of disease
o Use of pre-printed physician order
sheet
Policy and Procedure Development
Medication administration process
Medications administered in specific
locations
Education
Newsletter that includes clinical info on
Presentation at meetings, health-system
website
Regulatory & Accrediting Bodies
 RB: State Dept of Health , Board of o Therapeutic class review
Pharmacy evaluation of a group of
AB: TJC , AOA, Commission on medications w/ an established
Accreditation of Rehabilitation Facilities therapeutic class ; indication for
( CARF ) use, dynamics, ADE, drug
interactions
Pharmacist Role o Formulary changes
Establish P&T committee meeting o Nonformulary drug use review
Analyze & disseminate scientific, clinical
information New Product Evaluation ( standard
Conduct drug use evaluation elements )
Record & archive P&TC committee Generic name name of all chemical entities
Trade name
actions
Therapeutic / Pharmacologic Class
Follow-up w/ research
Pharmacology mechanism of action &
Communicate PTC decisions to other
pharmacologic effects
health care professionals Pharmacokinetics how drug is handled by
the body, onset of effect, serum half-life,
Formulary Management metabolic considerations, route of excretion
Open Formularies generally large, no Indications for use
limitation to access to a medication Clinical studies clinical study data
Closed formularies limited list of supporting indications for use ( statistical
analysis, outcomes, info on patient info )
medications to specific physicians,
Adverse effects/ warnings methods to
patient care areas, disease states via reduce , risk & benefit of drug therapy,
formulary restrictions precautions in pregnancy, etc
Drug interactions drug-drug, drug-food
Formulary Restrictions act of limiting the Dosage range dosage range for diff routes,
use fo specific formulary medications to age, hepatic function
specific physicians based on areas of Dosage form and cost table listing
expertise comparable agents may be useful in
Institute of Medicine ( IOM ) evaluated formulary addition
Summary
the Veterans Administration ( VA )
Recommendation formulary addition,
National Formulary impact on health care restriction, deletion
costs in six closed or preferred class of References peer-reviewed primary literature
drugs
FDS defines the equivalence of indiv Therapeutic Class review
chemical entities or generic equivalents Should not be too broad or all inclusive
o Approved Drug Products w/ New medical info, adverse event profiles,
Therapeutic Equivalence Orange purchase or use data
Book Objective; have the optimal agents w/in
Therapeutic Equivalents
each consideration
o Drug products w/ diff chemical
structure but same pharmacologic
Formulary Changes
/ therapeutic class and effects
Process to continually update the
( ex. 1st gen. cephalosporin ,
formulary must be established
histamine-2 blockers )
Submission of request for making
Therapeutic Interchange
o Authorized exchange of additions & deletions ( agent to be
therapeutic alternatives in added/deleted, rationale for request,
accordance w/ previously alternative agents )
approved guidelines ; must
include dosage strength, Nonformulary Drug Review
frequency, & route of Nonformulary agent medication not
administration part of drug formulary ; not considered
Guidelines for generic substitution but P&TC choosing to add it
o RPh is responsible for selecting Automating medication prescribing
generic drugs ; P&TC determines process
therapeutic equivalents o Computerized prescriber order
o Prescribers may specify a specific entry
brand if clinically justified o Order Entry Rules logic
Formulary maintenance ongoing established w/in the hospital info
process of assuring relative safety & system order entry module to
efficacy of agents available for use notify prescribers of adverse
o New product evaluation effects ; include weight based
 dosing, laboratory tests, allergy
checks
o Pop-ups info that appears on a
computer monitor when a specific
actions are taken ; may contain
clinical info about med use, drug
interactions
Drug Use Evaluation ( DUE )
Systematic process used to assess the
appropriateness of drug therapy by
engaging in the evaluation of data on
drug use
Medication Use Evaluation ( MUE )
encompasses the goals & objectives of
DUE in its broadest application
first established in 1980s
provide an ongoing, structured,
organized approach to ensure that drugs
are used appropriately
Outcome assessment systematic
process of evaluating the
appropriateness, safety, & efficacy of a
medication ; review of pt medical records
Multiple performance improvement
models
o FOCUS-PDCA ( or PDSA )
Find process to improve
Organize a team that knows
Clarify current knowledge
Understand causes of process
variation
Select process improvement
Plan ; Do ; Check ( or study ) ;
Act
Medication use criteria
o Diagnosis-related DUE criteria
identify indications for w/c select
drugs may be appropriate for a
given disease
o Prescriber-related DUE identify
specific physicians whom the
P&TC has determined may use
certain drugs
o Drug-specific DUE focus on
specific aspects of select drug
such as dose or frequency
Data should be collected during the
patient visit ( concurrent ) rather than
retrospectively ( chart review )
Technology: Personal Data Assistant
( PDA )
Task force should develop an action plan
& criteria
Action plan: devlpt of drug use
guidelines, preprinted orders, med order
netry rules, formulary changes