PANIQUI

HOSPITAL POLICIES AND

GENERAL
HOSPITAL PROCEDURES

DEPARTMENT OF PHARMACY |
HOSPITAL POLICIES AND PROCEDURES

Republic of the Philippines

Provincial Government of Tarlac
Municipality of Paniqui
Luis Tirso M. Rivilla Hospital
(PANIQUI GENERAL HOSPITAL)
Brgy. Samput National Highway

POLICIES AND PROCEDURES

DEPARTMENT: PHARMACY
PERSONNEL RESPONSIBLE:

 Staff Pharmacist
JOB DESCRIPTION:

 Fills prescriptions and dispenses pharmaceutical products.

 Compounds medications not commercially available.
 Labels all medicine container issued to various hospital services.
 Checks manufacture and expiration dates of drug products.
 Checks label of medicines in accordance with Bureau of Food and Drugs labelling
requirements
 Records issuances of medicines in the stock cards and accomplishes issue report forms
after every shift.
 Files and prescriptions for two (2) years.
 Notifies physicians on any therapeutic incompatibilities, potential drug interactions and
duplicate prescriptions.
 Ensures that the right patient takes the right drug and right dosage at the right time.
 Conducts daily/weekly/monthly inventory of medicines and supplies.
 Prepares, checks and signs charge slips issued to patients.
 Participates in research activities.
 Attends scientific seminar-workshops/consultative meetings and continuing education on
drug-related matters and hospital pharmacy practices.
 Participates in Continuous Quality Improvement (CQI) program of the Pharmacy
Service.
 Prepares Performance Evaluation System (PES)
 Perform other related functions as assigned by the immediate superior.

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POLICIES:

 There should be a well-established Pharmacy Service organized in accordance with

ethical and professional practices and has complied with One Stop Shop requirements of
the Bureau of Health Facilities Services (BHFS) for the issuance of the hospital License
to Operate (LTO); and with Comprehensive Dangerous Drugs Act of 2002 (RA 9165) to
acquire the S3 license.

 There shall be a Pharmacy and Therapeutics Committee for better patient care at a lower
cost, rational drug therapy and improved teaching on patients.

 Medicines shall be issued upon receiving of prescription signed by the attending

physician.

 Emergency drugs and antidotes shall always be made available to hospital treatment areas
such as ER, OR, DR, RR and ICU.

 The Standard Operating Procedures of the hospital shall be maintained and updated as it
serves as guide and ready reference for all the hospital pharmacy staff.

 Dangerous drugs shall be issued only upon presentation of the required prescription form.
The S2 license of the prescriber must be written in the prescription.

 Inventory system should be maintained adopting the First Expiry, First Out (FEFO) or
First In, First Out (FIFO) method, whichever is applicable.

 There should be work flow chart post in conspicuous area within the vicinity where
pharmacy services are rendered or performed.

 A written policy concerning stop orders shall be established to ensure that medication
orders are not inappropriately continued.

 Expiration of drug products delivered shall be 18 months from the date of delivery and
manufacturing date shall be two (2) years from the date of delivery.

 A 20% discount on the cost of medicines shall be provided to senior citizens.

 There should be a menu card displayed at the dispensing counter of the pharmacy. The
menu card should indicate all available medicines with complete specifications, dosage
forms, corresponding brand name (if any), an expiration date and cost.

 Official Receipts (OR) for medicines sold shall be prepared and issued by the cash clerk
based on the charge slips issued from the pharmacy.

 Records, files and reports on dangerous drugs should be maintained in compliance with
the pertinent laws, rules and regulations in RA 9165, Board Regulation No. 3 s.2003.

 Medicines delivered to the hospital should be inspected and checked in the presence of a
pharmacist.

 Expiration of drug products delivered shall be 18 months from the date of delivery and
manufacturing date shall be two (2) years from the date of delivery.

 Continuing education, training and seminars should be regularly provided to pharmacist

and support staff.

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SUBJECT: PHARMACY AND THERAPEUTICS COMMITTEE

POLICIES:

 Proposal for the inclusion of a drug in the hospital formulary already listed in the PNDF
should be made using the Formulary Drug Request Form.
 Investigational drug products must be approved by the appropriate regulatory agency for
the specific use of its principal investigator through the COH. Investigational drugs must
be evaluated and approved by the training and research department of the hospital.
 Pre-signing of blank prescriptions, for any purpose is prohibited.
 To make it easier for both patients and practitioners, two or more drug products are
allowed in one prescription for a particular patient.
 The pharmacy shall dispense drug products and dangerous drugs in accordance with the
implementing rules and regulations of the Generic Act of 1988 (RA 6675),
Comprehensive Drug Act of 2002 (RA 9165) and other pertinent DOH policies and
regulations
 Product defects or problems encountered with drug suppliers should be reported to the
hospital management through the PTC for appropriate action.

PROCEDURES:
1. Hospital Formulary System
- Process in which the list of drug products or formulary of the hospital is developed.
- It is the method where the medical staff of a hospital working with the Pharmacy and
Therapeutics Committee, evaluates, appraises, and selects from among the numerous
available medicinal agents and dosage forms those that are considered most useful in
patient care.
- The system provides the hospital pharmacists time to work with:

 The medical staff in the selection, evaluation of new drug products and critical use of
therapeutic agents, and in the promotion of rational drug therapy
 The nursing staff to avoid practices and procedures which may lead to medication errors
 Medical and nursing staff in the implementation of policies concerning the use of drug
products in the hospital.

Objectives:

 It serves to educate the physicians concerning the relative merits of the multitude of
available medicines to provide rational therapeutics and promote quality patient care.
 It serves as a teaching aid to the intern and other medical staff by providing essential
information on a well-classified arrangement of therapeutically known medicines, which
have been chosen after careful consideration by the medical staff.
 It prevents unnecessary duplication; wastage and confusion on prescribed medications
thus promote savings both to the hospital and to the patient.
 It promotes safe, intelligent, and effective therapy in a hospital.

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Factors to consider in preparing a hospital formulary;

 A formulary list should be limited to conserve resources.

 It is not necessary to stock all medicines listed in the Philippine National Drug
Formulary. Generic duplication should be eliminated.
 Medicines should be selected based on diseases and conditions treated at the health
facility.
 Medicines of choice should be selected comparing efficacy, safety, toxicity,
pharmacokinetic properties, bioequivalence, pharmaceutical and therapeutic equivalence.
 Cost effectiveness should be a primary consideration.
 Once medicines of choice are selected, they form the basis for standard treatment
guidelines and for therapeutic substitution.
 Second line alternatives to medicines of choice may be included when necessary.
 The hospital formulary should correspond with the current edition of the PNDF and to the
approved standard treatment guidelines.

Contents of a Hospital Formulary

 Title Page
 Names and titles of the members of the PTC
 Table of Contents
 Information on hospital policies and procedures concerning drugs/medicines.
o Objectives and operation of the formulary system.
o Hospital policies governing the prescribing, dispensing, and administration of drug
products standard including drug administration times.
o Pharmacy operating procedures such as hours of service, out patient prescription
policies, pharmacy changing system, prescription labelling and packaging practices,
inpatient drug/medicine distribution procedures, the handling of drug information
requests and other services as patient education programs and pharmacy bulletin.
o Information on using the formulary, including how the formulary entries are
arranged, the information contained in each entry and the procedures for looking up a
given drug product. Reference to sources of detailed information on formulary drugs
should be included.
o Pharmacologic category of medicines.
o Brief description of the PTC, including its members, responsibilities and operation.
o Policies on pharmaceutical company representatives.
o Procedures on reporting adverse drug events and medication errors.
 Drug Product List. This is the heart of the formulary. It consists of one or more
descriptive entries for each formulary item plus one or more indices to facilitate use of
the formulary.
 Information to be included in each entry may vary. At a minimum, each entry must
include the following:
o Generic name of the basic drug entity or product/combination products.
o Dosage forms(s), strength(s) packaging(s) and size(s) stocked at the Pharmacy.
o Formulation (active ingredients) of a combined product.
Formulary entries maybe arrange as follows:

 Alphabetically, by generic name.

 Alphabetically, within therapeutic class.
 A combination of the two systems in which the bulk of the drugs/medicines are contained
alphabetically in a general section which is supplemented by several special sections such
as ophthalmic/otic drugs, dermatological and diagnostic agents; or dosage form as oral
tablets and capsules, oral liquid/syrups/suspension, parenteral as ampoules/vials.

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 Drug listing indeces may be by generic name of drug items or by

therapeutic/pharmacologic index.
 Appendices
o Rules for calculating pediatric doses.
o Schedule of standard drug administration time.
o Forms for addition to/deletion from formulary and others
 Pharmacologic/Therapeutic Index
 Special information that may be included which are not readily available in other sources
such as:
o List of hospital-approved abbreviations
o Table of sodium content of antacids
o List of the contents of emergency

2. Hospital Formulary
- It is the cornerstone of drug management in the hospital, and is the principal
concern of the PTC.
- It is a continually revised compilation of pharmaceuticals, which reflects the
current clinical judgement of the medical staff and the relevant policies on
medication.
- It is tailored to fit the particular requirements of the hospital and reflects
departmental consensus on first choice treatment from the national list of
essential drugs.

Factors to consider in preparing a hospital formulary:

 A formulary list should be limited to conserve resources.

 It is not necessary to stock all medicines listed in the Philippine National
Drug Formulary. Generic duplication should be eliminated.
 Medicines should be selected based on diseases and conditions treated at the
health facility.
 Medicines of choice should be selected comparing efficacy, safety, toxicity,
pharmacokinetic properties, bioequivalence, pharmaceutical and therapeutic
equivalence.
 Cost effectiveness should be a primary consideration.
 Once medicines of choice are selected, they form the basis for standard
treatment guidelines and for therapeutic substitution.
 Second line alternatives to medicines of choice may be included when
necessary.
 The hospital formulary should correspond with the current edition of the
PNDF and to the approved standard treatment guidelines.

Contents of a Hospital Formulary

 Title Page
 Names and titles of the members of PTC
 Table of Contents
 Information on hospital policies and procedures concerning drugs/medicines.
o Objectives and operation of the formulary system.
o Hospital policies governing the prescribing, dispensing, and
administration of drug products standard including drug administration
times.
o Pharmacy operating procedures such as hours of service, out-patient
prescription policies, pharmacy charging system, prescription labelling
and packaging practices, inpatient drug/medicine distribution procedures,

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the handling of drug information requests and other services as patient

education programs and pharmacy bulletin.
o Information on using the formulary, including how the formulary entries
are arranged, the information contained in each entry and the procedures
for looking up a given drug product. Reference to sources of detailed
information on formulary drugs should be included.
o Pharmacologic category of medicines.
o Brief description of the PTC, including its members, responsibilities and
operation.
o Policies on pharmaceutical company representatives.
o Procedures on reporting adverse drug events and medication errors.
 Drug Product List
- This is the heart of the formulary. It consists of one or more
descriptive entries for each formulary item plus one or more indices to
facilitate use of the formulary.
 Information to be included in each entry may vary. At a minimum, each entry
must include the following:
o Generic name of the basic drug entity or product/combination
products.
o Dosage form(s), strength(s) packaging (s) and size(s) stocked at the
Pharmacy.
o Formulation (active ingredients) of a combined product.
Formulary entries may be arranged as follows:

 Alphabetically, by generic name.

 Alphabetically, within therapeutic class.
 A combination of the two systems in which the bulk of the drugs/medicines
are contained alphabetically in a general section which is supplemented by
several special sections such as ophthalmic/otic drugs, dermatological and
diagnostic agents; or dosage form as oral tablets and capsules, oral
liquid/syrups/suspension, parenteral as ampoules/vials.
 Drug listing indeces may be by generic name of drug items or by
therapeutic/pharmacologic index.
 Appendices
o Rules for calculating pediatric doses.
o Schedule of standard drug administration time.
o Forms for addition to/deletion from formulary and others.
 Pharmacologic/Therapeutic Index
 Special information that may be included which are not readily available in
other sources such as:
o List of hospital-approved abbreviations
o Table of sodium content of antacids
o List of the contents of emergency cart/boxes/cabinets (see medication
and related accessories for emergency treatment)
o Dosage guides for patients with impaired renal function
o Metric conversion scales and tables
o Examples of request for deletion/inclusion and prescription forms
o Provisions of the Generics Act on prescribing and dispensing
especially erroneous, violative and impossible prescriptions
o Table of drug interactions
o Poison antidote charts

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SUBJECT: DRUG PROCUREMENT/INVENTORY CONTROL

POLICIES:

 Regular monitoring of quality of drugs must be maintained to ensure they have not
deteriorated under storage conditions prevailing at each location.
 Storing and dispensing of medicine shall maintain a record on all drugs.
 Drug procurement shall maintain a systematic way.

PROCEDURES:
1. Cycle of Drug Procurement
1. Review drug selection
2. Determine quantities needed
3. Reconcile needs and funds
4. Choose procurement
5. Locate and select suppliers
6. Specify contract terms
7. Monitor order status
8. Receive and check drugs
9. Make payment
10. Distribute drugs
11. Collect consumption information

2. Key Principles of a Good Pharmaceutical Procurement

 Procurement by generic name

 Limitation of procurement to the essential drugs
 Procurement in bulk
 Formal supplier qualification and monitoring
 Competitive procurement
 Sole-source procurement
 Order quantities based on reliable estimate of actual need
 Reliable payment and good financial management
 Transparency and written procedures
 Separation of key functions
 Product quality assurance program
 Annual audit with publish reports
 Regular reporting of procurement performance indicator

3. Methods of Procurement

METHOD EFFECT ON PRICE LEAD TIME WORK LOAD

Open Tender Usually lowest prices Moderate to long High
Restricted Tender Favorable Moderate to long High
Competitive Can be favourable Short to moderate Moderate
Negotiation
Direct Procurement Usually highest prices Short to moderate Low

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4. Steps in the Requisitioning and Procurement of Drugs

1. The Pharmacist checks balance on hand in the stock card.
2. The Pharmacist prepares stock position sheet.
3. The Pharmacist prepares and signs the Purchase Request.
4. The Chief Administrative Officer reviews and affix initial in the Purchase Request.
5. The Chief of Hospital approves Purchase Request.
6. The Supply Officer accepts Purchase Request and prepares Purchase Order (PO).

5. Reselling and Dispensing Conditions for Consigned Drugs and Medicines

 The DOH hospitals shall be allowed to dispense and sell medicines under a duly
perfected Consignment Agreement.
 The DOH hospitals shall be authorized to dispense consigned medicines with mark-ups
provided that the resultant retail price, i.e. with the mark-up will not result to a price
higher than the prevailing market price.
 No consignment agreement shall be entered into the hospital if after computation of the
range of possible resultant mark-up prices until the level of break-even point, i.e. price
where no income will be earned by the hospital concerned would result to a price higher
than the prevailing market price.
 The DOH hospitals must maintain distinct records of sales of consigned medicines,
distinctly identifying the Consignor for the purpose of tallying records and payment.
 The label and packaging of the consigned goods shall be maintained as they are,
provided that the consigned goods are dispensed using their generic names only, among
the other essential requirement to be reflected in a prescription as provided by law and
pertinent statutes.
 Consigned medicines sold shall be issued with separate Official Receipts to facilitate
balancing of sales records and inventory.
 The foregoing procedure shall apply mutate mutandis to CHDs and other health units
provided that they are authorized to set up Trust/Revolving fund as approved by the
DBM and subject to issuance of specific guidelines.

6. Fast-Track Procurement of Specific Essential Drugs and Medicines

 A.O No. 34-A series of 2003, shall be applicable only for the procurement of patented and
off-patient medicines, with or without brand name, that are listed in the latest edition of
the Philippine National Drug Formulary (PNDF) or as approved by the National
Formulary Committee (NFC) and are highly sought after by the general public in the
different Department of Health Hospitals.
 Order shall only be applicable for DOH Botikas with Revolving Trust Fund facilities
established for the specific purpose of selling affordable medicines to the general public.

Objectives:

 Provide guidelines for the different DOH hospitals in procuring fast moving and highly
sought after essential medicines.
 Eliminate wastage attributed to none or slow moving medicines which expiry dates have
lapsed.
 Replicate good practices/strategies displayed by DOH units that are beneficial to the
citizenry.
 Concertize the government’s commitment in bringing down the cost of quality
medicines.

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7. Consignment System

 Administrative Order No. 5 s. 2003 (Guidelines and Procedure for the Institutionalization
of DOH Drug Consignment System) allows DOH hospitals to enter into a drug product
consignment agreement with legitimate manufacturers or suppliers which have the
capability to meet the demands of the hospital for essential medicines in a sustainable
manner.
 AO No. 145 s. 2004(Revised Policies and Guidelines for the Institutionalization and
Decentralization of the DOH Drug Consignment System) was created to decentralized
certain functions performed at the DOH central office level, and thereby empowering
DOH hospitals and Centers for Health Development (CHD).
 AO 145 s. 2004, AO No. 2006-0039 dated 8 December 2006 (Amended Policies and
Guidelines for the Institutionalization and Decentralization of the DOH Drug
Consignment System) was created for the following purposes:
 To provide a time-bound systems and procedures that would establish the DOH
Drug Consignment System (DOHCS).
 To define the attendant roles and responsibilities of perspective consignor and
Consignee.
 To provide safeguards that would ensure that the system is within the framework
of existing rules and regulations on procurement used by the Government in
general and by the DOH in particular.
 To amend specific provisions of A.O. No. 145 s. 2004

8. Preparation of Purchase Request

 To compute for the average consumption per day

Average consumption/day= Average monthly consumption

30 days

 To compute for stock level

Stock level= Average consumption/day * (90 days + Lead time)

 In the preparation of Purchase Request (PR), the following is considered:

 The information on available funds
 The conditions such as seasonal demand
 Delivery lead time
 Availability of alternate drugs
 The ratio of supply and demand

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9. Reselling and Dispensing Conditions for Consigned Drugs and Medicines

 The DOH hospitals shall be allowed dispense and sell medicines under a duly perfected
Consignment Agreement.
 The DOH hospitals shall be authorized to dispense consigned medicines with mark-ups
provided that the resultant retail price, i.e. with the mark-up will not result to a price
higher than the prevailing market price.
 No consignment agreement shall be entered into the Hospital if after computation of the
range of possible resultant mark-up prices until the level of break-even point, i.e. a price
where no income will be earned by the hospital concern would result to a price higher
than the prevailing market price.
 The DOH hospitals must maintain distinct records of sales of consigned medicines,
distinctly identifying the Consignor for the purpose of tallying records and payment.
 The label and packaging of the consigned goods shall be maintained as they are, provided
that the consigned goods are dispensed using their generic names only, among the other
essential requirement to be reflected in a prescription as provided by law and pertinent
statutes.
 Consigned medicines sold shall be issued with separate Official Receipts to facilitate
balancing of sales records and inventory.
 The foregoing procedure shall apply mutate mutandis to CHDs and other health units
provided that they are authorized to set up Trust/Revolving fund as approved by the
DBM and subject to issuance of specific guidelines.

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SUBJECT: Medication Storage, Security and Control

POLICIES:

 All medications are routinely stocked and stored under appropriate conditions to meet
the requirements for stability and only authorized personnel can access

PROCEDURES:
1. In Main Pharmacy:

 Controlled substances are stored in safe cabinets.

 Chemicals and medications that are used for extemporaneous preparations are kept
separately from the regular inventory and are labeled with contents, expiration dates and
appropriate warnings.
 Medications are arranged in shelves by category and labeled: Ophthalmics, Otics, Orals,
Injectables, Externals, Inhalations and miscellaneous.
 Brand name and generic name should be labelled to the medications.
 Medications that are sound-alikes are kept away from one another to prevent medication
errors. They are also labeled with TALL-MAN lettering for differentiation
 Oral formulations are stocked in unit dose per manufacturer or pre-packaged from bulk
bottles by Pharmacy Technicians.
 Expiry date must be checked by technicians monthly.
 Refrigerator temperatures are monitored and logged in twice daily for vaccine storage
 All large volume parental and electrolyte vials are stored in the outer area of the IV room
for limited access.

2. Methods of Proper Storage

 Keep the pharmacy and storeroom in good condition.

 Prevent damage and contamination.
o Physical Damage
o Dirt
o Infrastructure
 Protect against fire
 Arrangement of Medicines
 Provide sufficient shelves.
 Use a system for arrangement by: therapeutic category alphabetically by generic
name; by dosage form.
 Use color-coding system to monitor drugs/medicines movement.
 Implement DOH cold chain management on vaccines.
 Arrange medicines neatly and label shelves for each item.
 Store medicines in a way that facilitates FEFO (First Expiry-First Out) or FIFO
(First In-First Out) rule for stock management.
 Arrange cartons on plastic pallets pointing arrows up. Make sure that expiry and
manufacturing dates are visible on the label.
 Consistently monitor the temperature of the different areas within the pharmacy
and storeroom.
 Follow product manufacturer’s storage instructions.
 Keep expired medicines separate and label with “Not Fit for Consumption”.
Return them to the office of the Supply Officer for proper action and/or disposal.
 Use of visual discriminators such as signs or makers is helpful to differentiate
medications from one another.
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3. Storage of Medicines

1. The Pharmacist posts data of delivered drug products in the stock card.
2. The Pharmacist/ Administrative Aide systematically arrange the stocks
3. The Pharmacist/ Administrative Aide post details of delivered drug products in the bin
card.
4. The Pharmacist/ Administrative Aide arrange carton on pallets properly.

4. Storage of Controlled Substance

1. The Pharmacist posts data on the stock card the delivered dangerous drugs.
2. The Senior Pharmacist/Designated Pharmacist systematically arranges the dangerous
drugs in a secured cabinet.
3. The Senior Pharmacist/Designated Pharmacist keeps keys in a secured drawer.
4. The Senior Pharmacist/Designated Pharmacist monitors stocks daily.
 Controlled Substances (Dangerous Drugs)
 The security of this cabinet/vault should conform to the regulatory standards of
the Comprehensive Dangerous Drugs Act of 2002.
 One senior pharmacist should be designated and shall be responsible for the keys
of the controlled drugs cabinet/s or rooms. Only the authorized staff is allowed at
the restricted area.
 An updated record of dangerous drugs in the DDB book is required.
 Attractive/Expensive Items
 Expensive drug products and antibiotics that are prone to theft, abuse or misuse
should be stored in a separate locked area
 An updated record keeping and more frequent inventory taking than other items
are necessary.
 Flammables and Corrosives
 Bulk supplies of flammables such as alcohol and acetone should be stored in
special building or room.
 A separate building is best to reduce the risk of fire from spreading to the
pharmacy or central storeroom.
 Storeroom must be well ventilated, fireproof and fitted with an “explosion hatch”
as part of roof/wall.
 Small stock of flammables may be kept in a steel cabinet, in well ventilated
premises, away from open flames and electrical appliances
 Cabinet(s) should be marked “highly inflammable fluid” and must bear the
international hazard symbol.
 Always store flammable substances in their original container.

5. Flash Point of the Flammable Liquid

FLAMMABLE LIQUIDS FLASH POINT

Acetone and anaesthetic ether -18 degree Celsius
Undiluted alcohol 18 degree Celsius to 23 degree Celsius
Kerosene 23 degree Celsius to 61 degree Celsius

 Biological products, vaccines requiring refrigeration

 There should be sufficient biological refrigerator/ (s) or improvised ordinary
refrigerator(s) to store all necessary biological products, parenterals, suppositories
and others requiring refrigeration.
 Cold chain system is implemented to ensure the potency of vaccines from the
time of manufacture to the time it is given to the patient.

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 The contingency plan is posted on or near the improvised refrigerator/

pharmaceutical refrigerator as guide, ready reference and reminder for every
pharmacist and staff in the hospital pharmacy handling vaccines/biological
products.
 Vaccines should be arranged according to type, expiry date, duration of storage
and number of times they have been brought out to the field. Vaccines with the
earliest expiration date should be distributed or use first.
 Thermometers of the modified or pharmaceutical refrigerators should be properly
calibrated twice in a year to maintain the required storage temperature.
 There should be backup generators in case of electrical failures.

 Storage of Cytotoxic Drugs

 All stocks of cytotoxic drugs should be kept in a secure area, with access limited
to specified authorized personnel.
 Warning labels should be applied to all cytotoxic drug containers, as well as
shelves and bins where these containers are permanently stored.
 A register should be kept for all drug products with information on the quantity of
each drug/medicine stored. The register should contain information on the safe
use of each drug and the details of treatment for proper disposal in case of
accidents.
 Storage areas should be identified with a warning sign, and details of spill
procedures should be readily available.

6. Recommended Storage Conditions for EPI Vaccines

TYPE OF VACCINE IDEAL STORAGE

TEMPERATURE
Most Sensitive to Heat Oral Polio -15 degree Celsius to 25
degree Celsius
Measles (freeze dried) -15 degree Celsius to 25
degree Celsius
DTP 2 degree Celsius to 8 degree
Celsius
Least Sensitive to Heat BCG 2 degree Celsius to 8 degree
Celsius
Tetanus Toxoid (TT) 2 degree Celsius to 8 degree
Celsius
Hepatitis B 2 degree Celsius to 8 degree
Celsius

7. Care of Refrigerators and Freezers

 Ensure that the room is well ventilated and protected from outside light and heat.
 Place refrigerators about 10 cm away from the wall to allow movement of warm air.
 Ensure that each piece of equipment is permanently connected to the electrical supply.
 Keep doors and lids firmly shut.
 Clean refrigerators and defrost it regularly.
 Place bottles of water for maintenance of storage temperature.
 Do not keep food items in the refrigerator.

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SUBJECT: Inventory Management

POLICIES:

 The Pharmacist shall check the available stocks of all medicines daily, weekly and
monthly.

PROCEDURES:
1. Types of Inventory
a. Physical Inventory
- The quantity of inventory is determined through actual count of items
as contrasted with accepting the values shown in records. (bin and
stock cards).
- Semi-Annual Physical Inventory of drug products and other supplies is
a Commission on Audit requirement.
- Accuracy is maintained through “cycle counting” or to continually
count available drug products.
- Drugs/medicines received on the day of the inventory or shortly
thereafter shall not be counted and clearly marked “post inventory”.
b. Perpetual Inventory
- A system where information on inventory and availability is updated
in a continuous basis.
- It may be facilitated either through a manual system of visible index
cards or by means of an electronic data system.

2. Factors to Consider for an Effective Inventory Management

 The information on the balance of the budget for drugs/medicines.

 Selection of drug products to be held in stock
 The conditions such as seasonal demand
 Transportation and delivery time problems
 Availability of alternate drugs/medicines
 The ratio of supply and demand
 Regular monitoring of drug products in stock

3. Causes of Over and Under Stock of medicines:

 Ineffective purchasing process

 Inefficient monitoring and control systems
 Incomplete submission of technical requirements (e.g., BFAD test results) causing
delay in payment processing.
 Poor storage condition
 Inadequate space for storage
 Supplier’s out of stock problem.
 Geographical and climatic conditions

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SUBJECT: Disposal of Spoiled, Expired, Damaged Medicines

POLICIES:

 Medication disposal should follow federal and state laws for all prescription, controlled,
and over-the-counter medications.

PROCEDURES:
1. Waste Disposal
1. The Pharmacist segregates expired, damaged and spoiled medicines.
2. The Pharmacist accomplishes Waste Material Report.
3. The Pharmacist submits Waste Material Report to the Chief Administrative Officer or
Medical Center Chief/ Chief of Hospital.
4. The Pharmacist furnishes Waste Material Report to the Property Officer.
5. The Pharmacist returns spoiled, expired and damaged medicines to the Property and
Supply Officer.
6. The Property Officer submits request for disposal with attached appropriate documents to
the Resident Auditor.
7. The Resident Auditor inspects the items and determines the value of the items to be
disposed.
8. The Resident Auditor submits recommendation of proper disposal to the Chief of
Hospital/ Medical Center Chief
9. The Chief of Hospital forwards the documents to the Disposal Committee.
10. The Disposal Committee undertake disposal of items as recommended.
11. The Property Officer accomplishes Inventory and Inspection Report, Report of Waste
Materials or Invoice Receipt as basis for dropping items from the book of accounts.
12. The Pharmacist drops from the records quantity and value of disposed medicines

2. Responsibilities of the Pharmacist

 Waste minimization through proper storage and segregation

 Advocacy of proper health care waste management procedure
 Ensure adequate training for personnel assigned to segregation and disposal

3. Categories of Pharmaceutical Wastes

 Packaging Materials
 Expired/ unused/ spilt/ contaminated drugs
 Sharps
 Cytotoxic Wastes
 Empty Vials
 Medical supplies used in compounding solutions

4. Disposal of Pharmaceutical Wastes

 Packaging materials such as cartons, paper drug literature, ampoule beds are disposed in
black bags.
 Disposal of empty vials as covered under Bureau of Food and Drugs Bureau Circular No.
16 s. 1999
 Delay-to-decay process

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 Expired medicines in unopened containers are returned to the supplier in accordance to

the Returned Goods Policy of the drug company.

5. Waste Management and Disposal of Cytotoxic Waste

 Cytotoxic pharmaceuticals passed recommended shelf life, or returned from patients

 Sharps and syringes
 IV infusion sets and containers
 Ampoules and vials
 The cotton whool from bottles containing cytotoxic drug
 Remaining solutions, expired or contaminated stock
 HEPA Filters
 Contaminated personal protective clothing-gloves, disposable gowns and shoe covers
 Dressing and bandages
 Contaminated cleaning equipment (mops)

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SUBJECT: Dispensing and Filling of Prescription for In and Out Patients

POLICIES:

 The pharmacist/ responsible personnel must read the prescription 3 times before
dispensing to prevent wrong medication dispensing to the clients.
 The pharmacist/ responsible personnel must be aware of the violative, erroneous and
impossible prescriptions.
 The pharmacist/ responsible personnel must have a knowledge background on filling a
prescription of in and out patients.

PROCEDURES:
1. Dispensing Process

 Receive and validate prescription

o Name, age, weight, sex of the patient, form, dosage and strength
 Understand and interpret prescription
o Three (3) times of reading and comparison with the prescription
o Contact the prescriber if the prescription is not complete
 Correctly interpret abbreviations used by the prescriber (e.g. IM, TID).
 Confirm that doses are in safe range (check age/ sex/ weight).
 Correctly perform any calculations of a dose and issue quantity.
 Identify any common drug-drug interaction.
 Prepare dispensing items
o Write the label
 Section 31 RA 5921 of the Pharmacy Law (Labelling of Dispensed Medicines)
states that “Every box, bottle or package containing medicine sold or dispensed
by a pharmacist, based on prescription, there shall be pasted, affixed or imprinted
a seal, or label bearing among others, the name of the prescriber, date, the
number of prescription and the direction for its use.

 Administrative Order No. 63 s. 1989 Labelling Requirements:

1. Name of the patient
2. Generic name of the drug
3. Brand name
4. Quantity
5. Manufacturer
6. Dosage strength
7. Expiry date
8. Directions for use
9. Name of pharmacist
 Pick the right medicine from shelf
 Measure/ count quantity from the stock
 Pack and label medicine
 Check dispensed medicine against prescription and stock container
 Record issuances in the stock card
 Issue medicine to patient with clear instructions and advice.

2. Methods of Drug Distribution to In-patients

 Individual Prescription Order

o All medicines are retained in the pharmacy until receipt of the physician’s initial
order.

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 Floor Stock or Ward Stock System

o Selected drug products are stored in the nursing station in advance and the nurse is
responsible for all aspects of unit dose preparation as well as administration and refill
of used item for the pharmacy.
 Combination of Individual Prescription Order and Floor Stock System
o The primary means of dispensing is the use of the Individual Prescription Order
System but combined with a limited number of floor stock items (common non-
prescription medicines like paracetamol and other drug products such as rubbing
alcohol and disinfectants).
 Unit Dose Drug Distribution System (UDDDS)
o Pharmacy-coordinated method of dispensing and controlling medication in organized
health care settings depending on the specifics needs of the hospital.

3. In-Patient Drug Distribution

 Methods of Drug Distribution for In Patients

o Individual Prescription Order
- All medicines are retained in the pharmacy until receipt of the physician’s initial order
- Facilitates a convenient method for instituting patient drug charges and it provides
individualized patient service.
Advantages:
- This method allows the pharmacists to directly review Medication Orders.
- It provides interaction among pharmacists, physicians, nurses and patients.
- It provides an efficient inventory control.
- Proper charges and bill of all medications issued to patients.

 Floor Stock or Ward Stock System

- Selected drug products ares stored in the nursing station in advance and the nurse is responsible
for all aspects of unit dose preparation s well as administration and refill of used item from the
pharmacy.
Advantages:
- Readily available medicines for the patient.
- Less responsibility for the pharmacist.
Disadvantages:
- Increase medication error incidents as pharmacists has lesser chance to review medication
orders.
- Increase drug inventory at each nursing station or other patient patient care areas.
- Greater opportunity for pilferage
- Increase hazards associated with drug deterioration/ expiration
- Additional capital funds may be necessary to provide proper storage facilities for medicines in
every patient care area
- Additional nurse’s time required for handling medicines

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- May result to inaccurate patient charges

 Combination of Individual Prescription Order and Floor Stock System

- The primary means of dispensing is the use of the Individual Prescription Order System but
combines with a limited number of floor stock items.

 Unit Dose Drug Distribution System

- A pharmacy-coordinated method of dispensing and controlling medication is organized health
care settings depending on the specific needs of the hospital.

4. Flow of Unit-dose Dispensing

 Physicians’ medication order is sent to the pharmacy.

 Pharmacists verify the orders and place drugs in unit-dose carts
o Carts have drawers in which each patient’s medications are placed by the pharmacist
(one drawer per patients).
o Drawers are labelled with:
 Patient’s full name
 Ward, room and bed number
 For accuracy, the pharmacist must check each drawer before the carts are transported to
wards
 A medication administration recording form is placed on top of the cart. The nurse uses
this form to check and then affix his/her signature on the time of each medication
administration.
 The next day, the carts are retrieved from the wards and the pharmacist fills it with unit
doses for the next 24 hours.

5. Basic Aspects of Unit Dose System

 Medications are contained in single unit packages

 They are dispensed in as “ready to administer” form as possible
 Less than 24 hour supply of doses is delivered to or available anytime at the patient care
area.

6. Preparation of Patient’s Medication Profile

 Read the patient’s medical chart and prepare the medication profile. The medication
profile should contain the following:
 Patient’s name
 Ward and bed number
 Age and sex
 Date admitted
 Present working impression
 Weight
 Physician-in-charge
 Medical Social Service classification (for service patients)
 Copy the doctor’s order. Write the following based on category (parenteral, oral,
treatment, stat or PRN medications):
 Generic name of the drug product
 Brand name (in parenthesis)
 Dose and frequency
 Route of administration

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 Read the patient’s therapeutic sheet. The patient’s therapeutic sheet contains record of the
standing medication of the patient, shows the time of administration of each drug and the
compliance of patient to the therapeutic regimen.
 Copy the time of administration from the therapeutic sheet, copy the time of
administration. Use Blue/Black and red colored pen for time of administration (ex.
Blue/black pen from 7am to 6pm, red pen from 7pm to 6am) If time of administration is
not yet indicated in the therapeutic sheet, use the standard time of administration.:

OD/q24 - 8am
HS - 8pm
Q12 - 8am – 8pm
Q8 - 8am - 4pm - 12mn
Q6 - 6am - 12pm – 6pm – 12 mn
Q4 - 4am – 8am- 12nn – 4pm – 8pm – 12mn

Or ask the nurse in charge what time the drug will be administered to the patient.

 Sign the medical chart. Write the following on the lower side of the last order reviewed
on the medical chart:

 Noted by
 Signature over printed name (or trodat)
 Date of review

7. Updating the Patient Medication Profile

 Read the patient’s medical chart and note for any changes in the doctor’s order.
 If ordering for new drug product, the pharmacist must copy the doctor’s order, read the
patient’s therapeutic sheet and copy the time of administration.
 If the order is discontinue/shift/change dose and/or frequency, pharmacist must:
o Mark the old entry (use red colored ink to draw a double bar after the last time of
administration of the drug and a single line toward the edge of the medication profile
to indicate that it was discontinued, shifted or changed).
o Copy the doctor’s current order (make a new entry of the drug product based on the
current order of the doctor. Follow the guidelines for new drug/medicine order.
 Sign the medical chart. Write the following on the lower left side of the last order
reviewed on the medical chart:
o “noted by”
o Signature over printed name
o Date of review

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7. Filling of Prescription for In-Patient

1. The Nurse presents to the pharmacist, prescriptions/ medication orders with signature of
the attending physician.
2. The Pharmacist checks the completeness of the prescriptions and availability of
drugs/medicines.
3. The Pharmacist Fills prescriptions if patient is indigent, pay or PhilHealth. For PDAF,
DOH Indigency and PCSO patients, checks copy of referral letter monitoring sheet
before dispensing.
4. Prepares charge slips.
5. The Billing Section receives charge slips including hospital bill.
6. The Pharmacist if drug/medicine is not available, advices the Nurse/Nursing attendant/
patient/ relative for the available alternative drug product. If acceptable to the prescriber,
fills prescription. If not acceptable, carry out emergency purchase through petty cash,
cash advance or credit line.
7. The Pharmacist writes the drug/ medicine price on the prescription and/or prepares
charge slip for cash sales.
8. The Cashier receives payment and issues Official Receipt (OR).
9. The Pharmacist indicates OR number in the prescription/charge slips.
10. The Pharmacist issues medicine to patient.
11. The Pharmacist stamps OR as claimed.
12. The Pharmacist counsels patients.
13. The Pharmacist records medicines dispensed and files prescription and charge slips.

8. Filling Prescriptions for In-Patient through Automated System

1. The Nurse encodes medication order from patient’s chart into the computer.
2. The Pharmacist reviews prescriptions as to completeness of data.
3. The Pharmacist checks the availability of the medicine. If the drug is not available,
suggests an alternative drug/medicine to the prescriber through the nurse.
4. The Nurse calls the prescriber for the suggested alternative drug, calls back the pharmacy
for confirmation of the request.
5. The Pharmacist confirms/renders and prints the order (Confirmation means that charges
are automatically billed to the patient).
6. The Pharmacist fills the order and issues the medicines to the ward staff.
7. The Pharmacist gives instructions on storage and other precautions.
8. The Nursing Aide signs the printed copy of medication order as proof of receipt.
9. The Pharmacist files the signed printed copy.

9. Dispensing Practices for Outpatients

 Pharmacist receives the prescription from an “in window”, fills prescription and dispense
medicine to the patient at the “out window”

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10. Filling of Prescriptions for Out-Patients and the General Public

1. The Patient presents signed and complete prescription to the pharmacist.
2. The Pharmacist If medicines are available,
a. Notes prices on prescription
b. Prepares charge slips
c. Instructs patient to pay to the cashier
The Pharmacist suggests alternative medicines if medicines are not available.
3. The Cashier receives payment and issues OR to patient/client.
4. The Patient presents OR and prescription to the pharmacist.
5. The Pharmacist Indicates OR number on the prescription.
6. The Pharmacist stamps OR as “claimed”.
7. The Pharmacist issues medicine to patient.
8. The Pharmacist counsels patient.
9. The Pharmacist records medicine issued and files prescription.

11. Distribution of Vaccines

 Steps to ensure the proper collection and transportation of vaccines:

 Obtain the right amount of vaccines needed by preparing an inventory report and
calculating your vaccine requirements for a specific period.
 Make sure that you have enough storage facilities for your collected vaccines.
 Check the type and amounts of vaccine diluents and ice packs.
 Check the expiry date of the vaccines. Do not accept expired vaccines.
 Put fully frozen ice packs or cold packs around the sides and bottom of the
transport box.
Vaccines like DPT and Tetanus Toxoid could be damaged by freezing. Hence,
pharmacist should prioritize regular monitoring of these vaccines. Place frozen
ice packs on the table for five to ten minutes before packing so that the
temperature of the ice packs will not be lower than 0 degree Celsius.
 Pack the vaccines and diluent into the cold chain container quickly and properly.
 Take the shortest route to your destination.
 Transfer vaccines and diluent immediately to cold chain facilities (refrigerators,
freezers, cold room). In case there are no refrigerators or freezers then transport
box maybe used for temporary storage for not more than five days.

12. Guidelines for the Acceptance of Returned Medicines

 The medicines must be in good condition in the original package and should be returned
within the period specified by the hospital policy.
 The manufacturer’s seal must not be torn or broken.
 The label is intact and readable. The lot number and expiry date indicated on the label
must be the same as those of the stocks in the pharmacy.
 Returned loose tablets/capsules and refrigerated medicines are not acceptable.
 The official receipt must be presented/submitted.
 Justification letter from the prescriber indicating the reason for return must be attached.
A photocopy of Death Certificate may be required as deemed necessary.

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SUBJECT: Control of Dangerous Drugs

POLICIES:

 The Pharmacist must obtain S-3 license secured from PDEA before selling, procuring,
acquiring, dealing in or with specified dangerous drug preparations and drug preparations
in parenteral or tablet or capsule form.

PROCEDURES:

1. Persons Authorized to Engage in Professional Supply of Dangerous Drugs

Containing Controlled Chemicals
o A pharmacist, acting in accordance with the norms and standards of the pharmacy
profession, who supplies to another person on prescription or on requisition, in the
ordinary course of a pharmacy business.
 A licensed person provided that such supply at all times take place under the immediate
supervision of a pharmacist.
 A practitioner who, in accordance with the norms and standards of his or her profession:
o Administers the drug directly to a patient or animal in the ordinary course of
treatment
o Supplies the drug to a patient or for an animal in the ordinary course of treatment
from a place more than five (5) kilometre-radius from the place of business of a
pharmacy.

2. Prescribing and Filling of an Order in Emergency Situation

 Where the need for treatment is urgent in an emergency case, an ordinary prescription not
in DOH prescribed official form may be given, and shall be acted upon by the licensed
seller. The prescribing physician, dentist, veterinarian or practitioner shall inform the
DOH, copy to PDEA unit responsible for the area where the emergency occurred, in
writing within three days after issuing such ordinary prescription. Such prescription
should contain at the back of its statement of date and nature of emergency condition.
The prescription should clearly state the name and address of the patient, and the name
and the signature of the prescribing person.

 In cases of emergency where life or health is endangered, an order for dangerous drugs
made not in the prescribed form and duly signed by the purchaser should be recognized
by the license seller and forthwith supply the dangerous drugs do ordered. The purchase
order should be signed by the City/Municipal Health Officer or attending physician or
senior medical officer or police medical officer or military doctor or any available doctor
supervising the medical team or unit rendering medical service in the area where the
emergency occurred. The seller shall notify immediately the PDEA a written statement
of circumstances leading to the purchase and how the medicine was dispensed or
administered and to whom, within 7 days after the particular emergency situation has
ended.

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3. Emergency Situation Related to filling of Emergency Order and Prescribing

Dangerous Drugs
 The following are specified as falling within the category of emergency situation:
o As a result of man-made, natural and other disasters such as war in any form,
terrorist attack, rebellion, insurrection, typhoons, earthquakes, volcanic eruptions,
fire, deluge, grave accidents, epidemic, etc. to preclude prompt access to the
official prescription form or order form for dangerous drugs
o Where, in the opinion of the prescribing physician, the immediate availability and
administration of the dangerous drugs would save the life and/or alleviate the pain
of the patients.

4. Drug Preparations Containing Controlled Chemicals

 A pharmacist dealing in drugs containing controlled chemical, which requires

ordinary prescription containing an S-2 license of prescribing doctor shall
maintain and keep an original record of sales, purchases, acquisitions and
deliveries of such drug preparations, indicating therein:
 License number and address of the pharmacist
 Name, address and license of the manufacturer, importer or wholesaler from
whom the drugs have been purchased
 Quantity and name of the drugs purchased or acquired
 Date of acquisition or purchase
 Name, address and community tax certificate number of the buyer
 The name of the physician, dentist, veterinarian or practitioner issuing the
same and telephone number
 Quantity and name of drugs sold or delivered
 Date of sale or delivery
 In the case of supply on requisition in an institution, details of the dispensary,
ward or other place to which drug was supplied
 In the case of return, the name of the person to whom the drug was returned.

 A certified true copy or computer printout of such record covering a period of six
months, duly signed by the pharmacist or the owner of the drug store, pharmacy
shall be forwarded to the Board through PDEA, within fifteen days following the
last day of June and December of each year, with a copy thereof furnished the city
municipal health officer concerned.

5. False or Misleading Entries in Registers and Records

 Any person required to keep a register or other record under the Act and this
regulation shall not:
o Make or cause or permit to be made, an entry in or on it that is, to the
knowledge of that person, false or misleading
o Cancel, obliterate or alter any entry, except to correct an error

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6. Duty to Loss, Destruction or Discrepancies

 Any person required to keep register shall upon discovery, submit a written report
immediately to PDEA
o The loss or destruction of the register, or of the whole or any part of the
contents of the register
o Any discrepancy in the register, other than a mistaken entry.

7. Safekeeping of Dangerous Drugs and Controlled Chemicals

 Any person authorized:
 To import, export, manufacture, administer, supply or acquire a dangerous
drug or controlled chemical or their respective preparations
 To engage in professional supply of dangerous drugs or drug preparations,
in parenteral or tablet or capsule form containing controlled chemical as
the only active medicinal ingredient or contains controlled chemical and
therapeutically insignificant quantities of another active medicinal
ingredient containing controlled chemicals, shall while the drug or
chemical is in the person’s custody or control, keep it or cause it to be kept
in vault, safe or other prescribed secure storage or depot
 A person referred to in subsection (1) shall take such measures as the PDEA may
direct in writing to ensure that no unauthorized person has:
 Access to the combination, key or other means of access to any secure
storage facilities or depot containing a dangerous drug or controlled
chemical
 The drug or chemical contained therein.
 The licensed operator shall ensure that the safekeeping and handling of the
chemicals is in accordance with the requirements defined in the Material Safety
Data Sheet of the Chemical concerned.

8. Duties Where There is Loss or Theft of a Dangerous Drug or Controlled chemical

or Their Preparation

 Any person authorized:

 To import, export, manufacture, administer, supply or acquire a dangerous
drug or controlled chemical
 To engage in professional supply of dangerous drugs or drug preparations,
in parenteral or tablet or capsule form, containing controlled chemical as
the only active medicinal ingredient or contains controlled chemical or
therapeutically insignificant quantities of another active medicinal
ingredient shall immediately report to PDEA, in writing, the loss or theft
of any quantity of the dangerous or chemical in the person’s custody or
control and record relevant particulars of the loss or theft in the
appropriate register.

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SUBJECT: Prescription for Out Patient Department

POLICIES:

 The personnel responsible for prescription must know the violative, erroneous and
impossible prescriptions.
 The nurse must know that Emergency prescriptions are only done by the Physician.
 The nurses must assess before prescribing medications or referring to the physician
 Nurses are allowed only to prescribe medications for ROUTINE CASES and the
physician must check and affix signature before going to the pharmacy for dispensing of
the written medication.

PROCEDURES:
1. Prescribing Process
1. The Nurse gets Demographic Data gathering (Name, Address, Sex, Birthday).
2. The Nurse asks the chief complaint of the patient.
3. The Nurse assesses the patient (especially the body part where he complains of pain,
itchiness,etc.)
4. The Nurse takes vital signs of the patient.
5. The Nurse refers patient to the laboratory for different tests if needed.
6. For life threatening and priority situations, the Nurse refers patient to the physician.
7. For non-life threatening and simple cases, the nurse can prescribe but make sure to let the
physician sign the prescription.
8. The Physician prescribes medications for priority and emergency cases.
9. The Physician affix signature to the prescription.
10. The Nurse reads the prescription twice or thrice before giving it to the patient.
11. The Pharmacist is responsible for drug dispensing.

2. Information of a Prescription

 Full Name
 Complete address or Hospital Number
 Date of prescription
 Name and dosage strength of the drug
 Quantity of the drug to be dispensed
 DEA number and signature of the physician
 Frequency and route of administration.

3. Prescription Requirements

 Prescriber’s Information
o Signature
o Legibility
- The prescription must be legibly and indelibly printed and cannot be written in pencil.
o Prescriber’s address.
- The prescriber’s address must be specified and clear.

 Patient’s Information
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o Patient’s Address
o Patient’s Category
- Patient eligibility must be clearly identified in accordance with the Pharmaceutical Schedule. If
the prescriber has included this information on the prescription, the pharmacist may accept these
details as correct unless the Patient provides documented evidence to the contrary.

 Pharmacy Stamp
 Date of Dispensing
 Prescription Number

4. Guidelines in Filling of Ordinary Prescriptions as per Administrative Order No. 63 s.

2000

 Whenever an ordinary prescription (Rx) in duplicate copies is filled by a pharmacist it is

incumbent for the pharmacist to stamp the word “FILLED” diagonally across the original
copy when the full quantity is issued, returning the duplicate to the patient. For Rx filled
partially, the pharmacist must stamp the words “USED FOR ____________”, and return
both copies to the patient after recording the partial filing in the prescription book
pursuant to Sec. 3.3 of AO 63 s. 1989.

5. Violative, Erroneous and Impossible Prescriptions in Accordance with the Regulations of

the Generics Act of 1988 (AO No. 62 s. 1989 sec 4)

 Violative Prescriptions
o Where the generic name is not written.
o Where the generic name is not legible and a brand name, which is legible is written
o Where the brand name is indicated and instructions added (such as the phrase “no
substitution”) which tend to obstruct, hinder or prevent proper generic dispensing

 Erroneous Prescriptions
o Where the brand name precedes the generic name
o Where the generic name is the one in parenthesis
o Where the brand name is not in parenthesis.
o Where more than one product is prescribed on one prescription form

 Impossible Prescriptions
o When only the generic name is written but is not legible
o When the generic name does not correspond to the brand name
o When both the generic name and the brand name are not legible
o When the drug product is not registered with the Bureau of Food and Drugs

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SUBJECT: Clinical Pharmacy

POLICIES:

 Every clinical procedures of the pharmacy must be well documented from medication
intervention to patient monitoring for the adverse effects of the drug given.
 Pharmacist shall prepare antidotes and emergency medicines for allergic reactions.

PROCEDURES:
1. Features of a Clinical Pharmacy Service

 Physical presence of the pharmacist in the patient care area to perform to his/her
functions in close coordination with the doctor, nurse, and patient
 Interpretation of the doctor’s medication orders.
 Preparation of a patient drug profile
 Preparation of unit doses and endorsement to the nurse.
 Drug information in the patient care area (patient education and counselling)
 Monitoring of Drug Therapy
 Participation in the Cardio Pulmonary Resuscitation activity.

2. Clinical Pharmacy Implementation

1. The Physician reviews the patient chart in terms of medications administered to the
patient either on a 24-hour therapy, or that of the preceding day’s therapy.
2. The Physician performs patient rounds together with nurses and clinical pharmacists who
can be consulted for medication related issues.
3. The Nurse endorses the doctor’s orders to the clinical pharmacist after patient rounds.
At the Nursing unit:
1. The Clinical Pharmacist reviews and interprets all the medication orders in the patients’
charts during the shift.
2. The Clinical Pharmacist accomplishes Patient Drug Profile.
3. The Clinical Pharmacist checks each patient’s medication box.
4. The Clinical Pharmacist endorses patient medication and drug charges to the nurse.
5. The Clinical Pharmacist prepares the Medication Cards using color index.
6. The Clinical Pharmacist checks Daily Medication Administration Sheet.
7. The Clinical Pharmacist inserts pharmacy notes in patient’s chart, e.g. automatic stop
order for antibiotics.
8. The Clinical Pharmacist communicates drug-related concerns to the doctors and nurses.
9. The Clinical Pharmacist counsels patient on drug therapy including expected side effects
and precautions.
10. The Clinical Pharmacist interviews newly admitted patients for drug allergies.
11. The Clinical Pharmacist gives advice to discharged patients on take home medications
and reminds patients on next scheduled check-up.

At the Main Pharmacy:

1. The Clinical Pharmacist prepares unit doses in the central pharmacy.

2. The Clinical Pharmacist informs the ward nurse of pickup of the prepared medicines.
3. The Clinical Pharmacist finalizes drug/medicine fees.

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3. Patient Care Team

Physician
(Diagnose, Therapeutic Plans, Rational Drug Therapy)

Patient

Nurse Clinical Pharmacist

(Direct Patient Care) (Rational Drug Therapy, Monitoring Drug
Therapy, Drug Information, Unit Dose Drug
Distribution System)

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SUBJECT: Adverse Drug Reactions

POLICIES:
 The pharmacist shall make sure that emergency medicines and antidotes are always
prepared and available.

PROCEDURES:
1. Strategies to Prevent ADR
 Be updated on recent Safety Information from FDA (BFAD) regarding drugs of known
side effects. (Reports sent to FDA (BFAD) would allow the agency to pass information
on safety to other health providers and to the public).
 Improve Incident Reporting System. Simplify ADR to accommodate the hectic schedule
of health personnel.
 Create a better atmosphere for health care providers to report ADRs where the person
reporting error shall not fear repercussions or punishment. (Punishment is a deterrent to
reporting an error. If an error is not reported, nothing can be done to correct the situation
that created the potential for error. Health care providers find it difficult to acknowledge
mistakes).
 Rely more on pharmacists to advise physicians in prescribing medications and promoting
health care provider education on medications (allows pharmacists to participate in
patient rounds with the health care team).
 Improve the nursing medication and monitoring systems (changes may include bar
coding, along with the additional warnings on medications with higher potential for harm,
ex. Insulin, opiates, narcotics, potassium chloride, anti-coagulants).

2. Approaches in Reducing Incidents of Adverse Drug Reactions

 Take a detailed history as part of the clinical history.
 Drug therapy should be used when there is a clear indication for it and there is no
pharmacological alternative.
 As much as possible, multiple drug regimens should be avoided.
 Particular attention must be given to neonates and geriatric patients and those with renal,
hepatic, and cardiac diseases.
 The need for continuing treatment should be regularly reviewed to determine increase or
decrease of dose, or discontinuance of drug/medicine.

3. Reporting of Adverse Drug Reactions

 The Pharmacy and Therapeutics Committee, PTC (through its ADR subcommittee)
distributes forms to the nursing units.

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Flow Chart on ADR Report and Monitoring

Detector

Doctor, Nurse,

Pharmacist of Patient

Resident-on-Duty Nurse

If assessed as ADR, Attending Doctor Nurse fills up ADR Report Form,

to fill-up ADR Report Form forwards to Pharmacy

Final Report to be accomplished by

ADR sub-committee

Chief of Hospital

Bureau of Food and Drugs Unit

 Nurses, doctors, pharmacists, or patients shall accomplish the form completely and
submits it to the ADR subcommittee.
 The PTC evaluates the reports and endorses them to the Bureau of Food and Drug’s
Adverse Drug Reaction Monitoring Program/ BFAD-ADR Unit (BFAD Memorandum
Circular No. 5 s. 1994, dated April 20,1994).

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4. Rational Drug Use

 Factors affecting the rational use of drugs

o Safety
o Efficacy
o Need
o Affordability

 Steps in Developing a Strategy to Promote Rational Drug Use:

1. Identify the problem and recognize the need for action
2. Identify underlying causes and motivating factors
3. List possible interventions
4. Assess resources available for action

 Types of Medication Errors

o Prescribing Errors

Causes:
 Incorrect or confusing nomenclature (abbreviations, acronyms, symbols).
 Only standard nomenclature should be used.
 Inappropriate dose.
 Failure to specify strength.
 Failure to specify exact dose.
 Incorrect or unspecified route of administration or dosage form.
 Inappropriate delegation of authority
 Illegible written orders.
 Confusing oral orders.
 Failure to look at the total problem and the medication list of the patient
before prescribing.
 Failure to periodically assess the need for continued therapy.
 Incorrect interpretation of patient results, patient records
 Incorrectly interpret or incorrectly apply a published paper or written drug
protocol
 Incorrectly use, apply or calculate patient data
 Make an actual error transcribing the prescription of the medication(s)

o Dispensing Errors

Causes:
 Dispensing the wrong drug.
 Dispensing a drug of questionable quality and/or bioavailability
 Incorrect or incomplete labelling of the drug.
 Incorrect number of doses.
 Failure to specify or clarify drug scheduling.
 Failure to set-up efficient and safe distribution system.
 Failure to specify stop order times.
 Failure to pick-up an error made by the prescriber and proceeds to a supply
error.
 Misinterpret a correct order and proceed to make a supply error.

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o Medication/Administration Errors

Causes:
 Omissions. Failure to give or chart the drug, omissions for which there is no
apparent reason.
 Wrong dosage. The medicine cup is the greatest source of error with liquids,
especially with smaller volumes.
 Extra or unordered dose(s) given.
 Unordered medication. These errors occur when there is no order for the drug
or the wrong patient receives an ordered drug.
 Wrong dosage form or route of administration. Using a different form (tablet,
capsule, suspension, injection) or route (PO vs injection).
 Wrong time. Variously interpreted to be 30 minutes to 2 hours before or after
the dose is ordered.
 Deteriorated or outdated medication.
 Fail to pick-up an error made by the prescriber and/or pharmacy and proceed
to an administration error.
 Misinterpret an order and proceed to an administration error.

 Techniques to Minimize Medication Errors

o Safety is a system property.

 Cooperation among practitioners

 Builds transparency in system
 Information flow established within system
 Build checks within the system

o Identify system weaknesses

o Build staff competency

 Training and validation

- Require all involved to undertake specific training that demonstrates their
competence with verifying and processing orders
 Staff audit
- Ensure that staff are aware of existing policies and procedures and can
demonstrate their familiarity
 Keep updated

o Build quality processes and risk management

“What you don’t measure, you can’t improve”

 Robust tracking and reporting system

 Trigger tools to detect adverse drugs effects
 Encourage reporting

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SUBJECT: Intravenous Admixtures

POLICIES:

 The Pharmacist shall monitor proper storage and handling of drug products in the IV
admixture area.

PROCEDURES:
1. Flow of Intravenous Admixture Orders

Physician Prescribes Admixture prepared

Nurse reviews order Expiration time

indicated on the
label

Admixture order is
sent to the Pharmacy checks the
Pharmacy prepared solution

Pharmacy reviews Admixture is

the order delivered to the
ward

S
Incompatibilities
checked, admixture Nurse receives
scheduled and admixture
profile reviewed

Nurse verifies
Pharmacist enters admixture against
order on patient’s physician’s order
profile

Admixture
Pharmacy prepares administered
label

Components
assembled

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2. General Procedures for Intravenous Admixture

 Unless the order specifies a particular start time or is to be initiated as a fluid change
with the next bag, all IV orders shall be entered to start “now” and should be filled and
sent to the ward as soon as possible.
 All IV admixtures are checked by another pharmacist (not the pharmacist who prepared
it) before delivery.
 At an appropriate time prior to the next preparation schedule, the corresponding labels
should already be prepared.
 Intravenous admixtures delivered to the nursing units should be stored in the refrigerator
unless the item has a “Do Not Refrigerate” auxiliary label.
 Intravenous admixtures that require protection from light shall be stored and dispensed
in brown light-resistant cover bags.

3. IV Admixture Solutions/ Preparation

 Large volume parenterals (LVP)

- IV fluids with or without additives intended to be administered by
intravenous infusions
- These consist of single-dose injections having a volume of 100 mL to
1000 mL.
- The commonly used mini-type infusion containers are 250 mL capacity
and 100 mL partial fills for solutions of drugs intended for “piggyback”
technique.

 Small volume parenterals (SVP)i

- Consist of single-dose IV injections having a volume of less than 100 mL.
- Includes 50 ml partial fills for solutions of drug used in “piggyback”
infusion and IV push preparations which are being administered over a
short period of time.

 Unit dose injections

- Parenteral preparations in single dose, ready-to-administer aspirated in
syringes.

4. Required Set-Up of IV Admixture Service

 Facilities
- A centralized admixture service could be located in a reasonably small
area of the pharmacy.
- The admixture preparation area should be located in a low-traffic area
within the pharmacy.

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 Equipment
 Typewriter
- For the preparation of a standardized admixture labels.

 Computer
- Generating labels
- Maintaining a profile of current orders
- Screening for incompatibilities and duplication orders
- Generating patient charges
- Maintaining work load and product usage records
- Generating mass production or batch compounding workshops

 Laminar Flow Hood (LFH)

- was designed to reduce the risk of airborne contamination during the
preparation of IV admixtures by providing an ultra clean
environment.
- The most important part of a laminar flow hood is a high-efficiency,
bacteria-retentive filter. \
- The room air is taken into the unit and passed through a pre-filter to
remove gross contaminants such as dusts and lint.
- The high-efficiency particulate air (HEPA) filter removes nearly all
bacteria from the air, 0.3 micron.

Functions of LFH:
o Provides clean air in the working area.
o Prevents room air from entering the LFH.
o Suspends and removes contaminants introduced in the work
area by the material or personnel.

LFH is used in the hospital pharmacy in the following:

o Preparation of IV admixtures (e.g. TPN solutions)

o Filling unit dose syringes
o Reconstruction of powdered drugs
o Preparation of miscellaneous sterile products

 Supplies
o Needles
o Syringes
o Filter
o Administration sets
o Gauze
o Cotton
o Alcohol
o Plaster

 Solution Containers
- Sterile empty evacuated containers

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 Protective Clothing
- Protective clothing should be considered mandatory for all health care
staff involved in the preparation of IV admixture solutions.
o Sterile gowns
o Headwear (cap) that fits snugly around the head
o Sterile gloves
o Surgical face masks

5. Labelling Requirements
 The label on a parenteral solution must provide the physician or other user with
all information needed to assure the safe and proper use of the therapeutic agent.
 The label should be pasted upside-down so that the information on it can easily be
read when the bottle is inverted, once placed in a hanging position.
 For LVP’s and some SVP’s, the size of the label should cover a major portion of
the manufacturer’s label, leaving only the name of the original solution visible.
 Label should contain the following:
 Name of Patient
 Ward, room and bed number
 Date and time of preparation
 Name of drug and contents
 Dose and frequency
 List of additives and their quantities (for TPN and other preparations which
contain more than one drug)
 Rate of IV infusion
 Expiration date (including the specific time)
 Name and signature of pharmacist who prepared the solution
 Countersignature of the pharmacist who checked the solution
 Special precaution, storage requirement, and instruction

6. Intravenous Admixture Incompatibilities

 An IV admixture is said to be incompatible when the prescribed drugs cannot be
combined safely and satisfactorily.
 It may lead to the formation of toxic products having an adverse effect on the
patient.

Types of Incompatibilities

 Physical Incompatibilities
- Occur when two drugs/medicines combined in a solution produce a change
in the appearance of that solution. This visual change may be recognized as a
change in color, evolution of a gas, development of a haze, or formation of a
precipitate.

 Chemical Incompatibilities
- Occur when two drugs/medicines react to cause the chemical degradation of
one or both drugs. This type of incompatibility may not be detected visually,
but its occurrence can be detected by analytical methods.

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 Therapeutic Incompatibilities
- Occur when two drugs/medicines are administered together to produce a
response differing in nature or intensity from that intended. Therapeutic
incompatibilities generally occur at the site of the drug action, example, at the
bacterial cell wall.

Factors Affecting Compatibility

 Ph OF admixture
- The most common cause of incompatibilities is a combination of two drugs
that results in a pH unsuitable for one of them.

 Complexation
- A reaction between products that inactivates them, example: combination of
tetracycline with a calcium-containing drug. The chemical complex formed
between tetracycline and calcium reduces the antibacterial activity of
tetracycline.

 Light
- Exposure of some drugs to light may cause destruction or reduce the potency
of the drug.

 Degree of Dilution
- The concentration of the drug or its degree of dilution in solution may be a
factor in its compatibility with other drugs. Up to 15 mEq of calcium can be
added to a liter of solution containing to 30 mEq of phosphate without
precipitation occurring. Higher concentrations of either drug, however, result
in precipitation.

 Time
- Most drugs/medicines degrade in a relatively short time when placed in an
IV solution. Similarly, many incompatibilities are not instantaneous, but
develop over time.

 Parenteral Solution
- Some drugs/medicines have very specific directions for their preparations.
For example, amphotericin B must be reconstituted with sterile water for
injection without a bacteriostatic agent and then further diluted only with 5%
dextrose injection. Amphotericin B is not compatible with normal saline. Not
only is the solution designated as 5% dextrose injection but the PH must be
above 4.2.

 Temperature
- The degradation of a drug/medicine may be regarded as a chemical reaction.
Heat increases the rate of most chemical reactions. Thus, one would expect
solutions to be more stable at refrigeration temperature than at room
temperature.

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 Buffer capacity of additive or solution

- The buffer capacity of a solution is the ability of that solution to resist a
change in pH either an acidic or basic (alkaline) substance is added to it. In
general, solutions that contain lactates and acetates have a relatively high
buffer capacity when compared to normal saline or 5% dextrose injection.

 Order of mixing
- The order of adding drugs/medicines to the solution maybe a factor in
incompatibility. If two drugs are not well diluted before they come in contact
in the solution, they may react chemically. When making parenteral nutrition
solutions, incompatible electrolytes such as calcium or magnesium with
phosphate are commonly prescribed. By adding the electrolytes last and
mixing well after each condition, the electrolytes are well diluted, when they
come in contact with each other, and the chance of precipitation.

Minimizing Incompatibilities

 Use solutions promptly after preparation in order to assure administration of

the most stable product, since the degradation of many drugs is time-related. If
freshly prepared admixtures cannot be used immediately, they should be
refrigerated.
 Minimize the number of drugs added to one solution. As the number of drug
additives increases, the possibility of incompatibilities increases at a higher
rate. When more than two drugs are combined in a solution, it is difficult to
find adequate information on the compatibility of the admixture.
 Check incompatibility references closely if one of the drugs has a very high or
very low pH. Because most drugs are acidic, their combination with a drug
having a very high pH, such as sodium bicarbonate or aminophylline, is very
likely to result in an incompatibility.
 Check incompatibility references closely when one additive is a calcium-
containing drug, because calcium causes precipitation of many drugs.

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