PhCare 331: Hospital Pharmacy

Pharmacy and Therapeutics Committee (PTC)

Pharmacy and Therapeutics Committee (PTC)
---- is a committee of the medical staff chaired by a physician, the director of the pharmacy is the secretary. It is an advisory group of
the medical staff and serves as the organizational line of communication or liaison between the medical staff and the pharmacy
department. It is also a policy-recommending body to the medical staff and to the administration of the hospital on all matters
related to the use of drugs.
Members of the PTC:
representative from: medical staff specialties, pharmacy, nursing service, administration, laboratory and other
pertinent departments
 Purpose:
✓advisory : recommends the adoption or assists in the formulation of broad
professional policies regarding evaluation, selection, procurement,
distribution, use, safe, practices, and other matters pertinent to drugs in
hospitals.
Educational: recommends or assists in the formulation of programs designed
to meet the needs of the professional staff (doctors, nurses, and the
pharmacist) for complete current knowledge on matters related to drugs and
drug practices.

 Functions of the P & T Committee:

a. establishes and maintains the formulary system (Formulary System
Maintenance)
b. selects medications for formulary inclusion (Medication Selection an Review)
c. evaluates medication use and related outcomes (Medication Use Evaluation
(MUE))
Other names of MUE: Drug Usage Review (DUR)
Drug Usage Evaluation (DUE)
d. prevents and monitors adverse drug reactions and medication errors
(Medication Safety Evaluation)
 medication safety is evaluated through:
ADR and medication error reports (basis for deletion,
addition, retention)
Committee’s Role in the ADR Program
an Adverse Drug Reaction Report Form should be prepared by
the PTC
>ADR Report Form – available on every nursing station
* Adverse Drug Reaction (ADR) is a response to a drug that is noxious and unintended, and that occurs at doses
normally used in humans for the prophylaxis, diagnosis, or therapy of diseases, or for the modification of physiologic
function. (WHO definition) ( Remington, 21st edition, page 1221)
Type of ADR: Type A (Augmented) , B (Bizarre) , C (Continuous) , D (Delayed) , and E (End of Use)
Note: Further elaboration on this will be done during discussion.

The PTC serves as a potent force in helping the pharmacist establish adequate specifications for the purchase of quality
pharmaceutical and educates health professionals to the optimal use of medications (Education) by assisting in development of
programs to educate health care professionals or patients regarding medications which can be communicated through
newsletter, website, email and meetings

Pharmacist’s role in PTC is being the secretary with following responsibilities :

 establish PTC meeting agenda
 conduct drug use evaluation
 analyze and disseminate clinical and health economic information regarding
a medication for review by the committee
participates in formulating policies and procedures for handling
investigational medications in the hospital
record PTC actions
 communicate PTC decisions to health care professionals
 follow up with research when necessary
❖ The committee is responsible to the medical staff as a whole and its recommendations are subject to approval by the
organized medical staff as well as the routine administrative approval process.

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Formulary System
It is a system that methodically evaluates medications on an on going basis for inclusion or exclusion, establishes
guidelines for optimal medication use, and develops policies and procedures for prescribing, dispensing, and
administering medication. PTC manages the formulary system.

The need for hospital formulary is due to:

a.) increasing number of medications available
b.) increased utilization due to direct consumer and physician marketing
c.) obligation of healthcare providers to exercise good stewardship

The advantages of a formulary system is that it provides a systematic method. On the other hand, disadvantage of a
formulary system limits the access to clinically indicated medications which may have an impact to the reduction of
quality of care;

Elements of the formulary:

* title page
* table of contents
* medication list
* medication use guidelines
* special information
* indexes
Formulary has no standard format but at least it must be easy to use, the sections may have different color or
visually appealing, the generic name must be bold, portable – pocket size, preferably an electronic version and posting
on website is encourage. It must also revised and published regularly (ideally annually) through addition, deletion, and
change in drug products, removal of drugs from the market, changes in hospital policies. The changes must be published
either in a form of newsletter or online dissemination. Lastly, it should be readily available for use of everyone in the
hospital;

Information provided by the formulary:

I- medications approved for use
a. arranged alphabetically by generic name with trade name, therapeutic class or combination (listed by
generic ingredients and trade name)
b. each drug entry contains generic name (active ingredients, therapeutic information), trade name or
synonyms, dosage form, strength, size, special precautions (e.g., for IM use) and cost
II - medication use policies and procedures in prescribing, dispensing and administration
III - policy for inclusion – usually depend per institution
IV - detailed guidelines for medication use
V - nutritional products approved for use
VI - examples of forms: nonformulary drug requests form and ADR report form, etc.,
VII- pharmacy operating procedures hours of service, prescription policies and medication distribution system

Nonformulary Drugs Management

A. policy for the use:
✓pharmacist contacts the prescriber to offer alternatives
✓completion of nonformulary request form by the prescriber or authorization from the
PTC chair prior to prescribing
B. procurement:
✓should be communicated to the pharmacy staff, medical staff and nursing staff
✓indicate a 24-hour delivery time
✓may permit the use of patient’s own medication in concert with hospital policies
C. regular review of nonformulary drug use by the PTC as to the agent used, formulary alternatives, number of
times used in previous 6 -12 months, patient’s safety and cost impact

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Distribution System
A. Dispensing Responsibilities

Dispensing is the provision of drugs and other pharmaceutical products to both in- and out- patients. Dispensing of
medications are after evaluation and interpretation of prescription and/or medication order.

Prescription is an order for medication issued by a physician, dentist, or other properly licensed medical
practitioner. A prescription designates a specific medication and dosage to be prepared by a pharmacist and
administered to a particular patient. A prescription is usually written on preprinted forms containing the traditional
symbol (meaning ‘‘recipe,’’ ‘‘take thou,’’ or ‘‘you take’’), name, address, telephone number, and other pertinent
information regarding the physician or other prescriber. FOUR MAIN Parts of prescription:

1. The superscription which consists of the heading where the symbol Rx (an abbreviation for recipe, the Latin for take
thou ) is found. The RX symbol comes before the inscription.
• Rx - Traditional symbol for prescription
2. The inscription is also called the body of the prescription, and provides the names and quantities of the chief ingredients
of the prescription. Also you find: drug name, dose (Quantity of drug per dose form), dosage form (The physical entity
needed i.e. tablet, suspension, capsule, syrup)
3. The subscription, which gives specific directions for the pharmacist on how to compound the medication.
These directions to the pharmacist are usually expressed in contracted Latin or may consist of a short sentence such as:
"make a solution," "mix and place into 10 capsules," or "dispense 10 tablets." However, that was in the old days. Today...
doctors just name the pill!
4. The signatura (also called sig, or transcription), gives instructions to the patient on how, how much, when, and how long
the drug is to be taken. These instructions are preceded by the symbol “S” or “Sig.” from the Latin, meaning "mark."

Types of Prescription:
• Erroneous - prescription become erroneous when the brand name precedes the generic name, or when the
generic name is in the parenthesis, here the brand name is not in parenthesis where more than one drug product is
prescribes on one prescription (applicable in dangerous drug prescribing). Erroneous prescription shall be filled, shall be
kept by the pharmacist and reported to the nearest DOH office.
• Violative - a prescription is violative when the generic name is not written, when the generic is not legible and a
brand name which is legible written and when brand name is indicated and an instruction added (such as “no
substitution”) which tend to obstruct, hinder or prevent proper generic dispensing. Violative prescription shall not be
filled, they shall be kept and reported by the pharmacist to the nearest DOH for appropriate action. The pharmacist shall
advise the prescriber of the problem and/or instruct the costumer to get the proper prescription.
• Impossible - prescription is impossible when generic name is written but it is not legible, when the generic name
does not correspond to the brand name, when both the generic name and the brand name are not legible and when the
drug product prescribed is not registered with the FDA. Impossible prescription shall not be filled. They shall be kept and
reported by the pharmacist to the nearest DOH office and instruct the customer to get the proper prescription.

Sources of Drugs:

• Natural - which came from plants and animals

• Semi-synthetic - natural products that have chemically modified to increase its potency and decrease side effects
• Synthetic - those that originated purely in the laboratory

Classification of drugs and Social Acceptability:

• Over-The-Counter (OTC) - those drugs that are available to everyone with prescription (ex. Aspirin , paracetamol)
FDA criteria for OTC:
--must be safe and effective without he supervision of a licensed practitioner, Have a low potential for misuse and abuse,
Treat conditions that are common, benign, and self-diagnosable by the average person, Have labeling instructions
understandable to the average person who will use the product
• Permitted non-medical drugs- available in food, beverages and tobacco (caffeine, nicotine, and alcohol)
• Prescription drugs - requires authorization from medical practitioner(doctor, dentist, veterinarian) Ex. Antibiotics
and contraceptive pills
• Controlled substances: Controlled Substances are divided into 5 schedules based upon their potential for abuse:
[Schedule I-IV, for examples, please refer to the notes below]

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In hospitals, the forms are somewhat different and are referred to as medication orders. In a typical medication
order sheet, the orders and instructions are written by the physician in ink. The medication order generally contains the
following information:
• Doses: including the quantity of a prescribed dose, the total number of doses prescribed, and the number of days the
prescribed medication will last.
• Compliance: the patient’s or caregiver’s compliance in meeting the prescribed directions for dosing.
• Drug concentration: the quantity of an active therapeutic ingredient to use to achieve the
desired drug concentration.
• Rate of drug administration: the quantity of drug administered per unit of time to meet prescribed
dosing schedule (e.g., mg/min, drops/minute, or mL/hr for the administration of an
intravenous fluid).
• Compounding: the quantities of active and inactive components to use in the extemporaneous
preparation of a pharmaceutical product, including the use of stock solutions and/or prefabricated
dosage units in the process.
• Chemical-physical factors: including calculations to make solutions isotonic, iso-osmotic, equimolar,
or buffered.
• Pharmacoeconomics: including medication costs, cost-benefit analysis, cost-effectiveness analysis,
alternative treatment plans, and medication pricing.

It is the responsibility of the pharmacist to ensure that each prescription and medication order received is
correct in its form and content; is appropriate for the patient being treated; and is subsequently filled, labeled,
dispensed, and administered accurately. In essence, each medication should be:

• therapeutically appropriate for the patient;

• prescribed at the correct dose;
• dispensed in the correct strength and dosage form;
• correctly labeled with complete instructions for the patient or caregiver; and
• for the patient in a hospital or other health care facility, each medication must be administered to the correct
patient, at the correct time, and by the correct rate and route of administration.

Dispensing of controlled substances

Controlled Substances are divided into 5 schedules based upon their potential for abuse:
Schedule I:
✓have high potential for abuse
✓no accepted medical use in the U.S.
✓includes: opiates ( from opium) eg: morphine, apomorphine,
codeine, papaverine
✓hallucinogens; cannabis, LSD
Other drugs under Schedule I:
Ex: heroin, psilocybin, Marihuana, LSD , Mescaline , Tetrahydrocannabinols (THC), dihydromorphine, and others

Schedule II:
✓have high potential for abuse
✓have a currently accepted medical use in treatment in the U.S.
✓may lead to severe psychological or physical dependence broad categories in this schedule are:
✓opium derivatives
✓derivatives of coca leaves
✓certain CNS stimulants and depressants
Drugs under Schedule II:
Ex: opium cocaine hydromorphone (Dilaudid)
morphine codeine methadone (Dolophine)
pantopon oxycodone meperidine (Demerol)
amobarbital; etorphineHCl anileridine (Leritine)
pentobarbital; diphenoxylate oxymorphone (Numorphan)
secobarbital phencyclidine methamphetamine (Desoxyn)
phenmetrazine (Preludin) methylphenidate (Ritalin)
amphetamine (Benzedrine; Dexedrine)

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Schedule III:
✓have accepted medical use in the US
✓have lower potential for abuse than schedule I and II drugs
Drugs under Schedule III
glutethimide paregoric
methyprylon (Noludar) clortermine
benzphetamine nalorphine
chlorphentermine phendimetrazine
any suppository dosage form containingamobarbital, secobarbital, or pentobarbital
Non-narcotic drugs
ex: derivatives of barbituric acid except those that are listed in another schedule
Schedule IV:
✓have low potential for abuse than schedule III
✓abuse may lead to limited physical dependence or psychological dependence than compared to those
in schedule III; Drugs under Schedule IV:
long acting barbiturates chloral hydrate certain hypnotics
ethchlorvynol minor tranquilizers propoxyphene
barbital ethinamate phenobarbital
pentazocine methylphenobarbital meprobamate
chloralbetaine paraldehyde oxazepam
methohexital clorazepate fenfluramine
flurazepam diethylpropion clonazepam
phentermine prazepam chlordiazepoxide
lorazepam diazepam mebutamate

Schedule V:
✓have the lowest abuse potential
✓consist of preparations containing limited quantities of certain narcotic drugs generally
for antitussive and antidiarrheal purposes
✓are OTC preparations - sold without a Rx

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References:
Brown, T. (2010). Introduction to Hospital and Health-System Pharmacy Practice. Bethesda: American Society of Health-System
Pharmacists
Gennaro, A. et.al. (2000). Remington’s Pharmaceutical Sciences, 20th ed., 2000, Pennsylvania: Mack Publishing Company.

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