Effective Date of This Revision: January 9, 2009
Contact: Medical Director 310-679-9126, Administration
Applies to:
• Officers
• Other agents
• Staff
• Visitors
• Student clinicians
• Contractors
• Volunteers
• Subcontractors / Business Associates
PURPOSE:
The purpose of this document is to outline policy and procedures for the establishment, role and responsibility of the Pharmacy and Therapeutics Committee in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.
POLICY:
Each Chemical Dependency Recovery Hospital shall maintain a Pharmacy and Therapeutics Committee, which shall act in an advisory capacity to the facility administration, the medical staff and the Board of Directors concerning all aspects of medication management.
The Committee shall consist of at least the Medical Director or Alternate Physician, the Consultant Pharmacist, the Director of Nursing (DON) and an administrative representative. The Medical Director or Alternate Physician shall serve as Chairperson of the Pharmacy and Therapeutics Committee.
PROCEDURES:
The Pharmacy and Therapeutics Committee shall:
• Meet at least quarterly. A permanent record of these meeting shall be maintained. Smaller subcommittees may meet ad hoc to review specific issues and make recommendations to the full committee.
• Assist in the formulation and annual review of facility policies and procedures regarding medication management. Develop and review at least annually the facility formulary. Additions and deletions shall be reviewed and approved by the committee routinely as necessary.
• Review in detail all reported adverse drug reactions and if determined appropriate, report to the United States Pharmacopeia.
• Review the Pharmacist’s Monthly Report and quarterly Quality Assurance (QA) Report.
• Review the Residential Unit Medication Audit
• Review all medication-related Incident Reports.
• Review the results of other pertinent audits and inspections done by county, state, federal and/or privately contracted agencies.
• Define problems that are identified through the review activities stated above.
• The quality and appropriateness of patient care shall be monitored, evaluated and reported through the following modalities:
• The Committee shall establish an objective criterion that reflects current knowledge and clinical experience and which can be used in the evaluation and monitoring of patient care services that pertain to medication management.
• The Pharmacy and Therapeutics Committee shall make recommendations for corrective action when problems are identified. All recommendations shall be documented. The effectiveness of such actions shall be monitored and evaluated by the Quality Assurance Committee and the conclusions of the Quality Assurance Committees shall be reported to the staff and governing body.
• The Chairperson of the Pharmacy and Therapeutics Committee shall be responsible for identifying important aspects of care to be monitored, and for ensuring that monitoring, evaluation, and problem-solving activities are carried out in a planned and systematic approach, as described and reported.
• The effectiveness of the monitoring, evaluation, and problem-solving activities pertaining to pharmacy services shall be appraised annually by the Pharmacy and Therapeutics Committee and reported to the Q.A. Committee and the governing board.
