standard operating procedures hospital

8/10/2019 Standard Operating Procedures Hospital

1/5

DR. TOMAS L. NOLASCO SR. HOSPITALCentro Sur, Gattaran, Cagayan

DTLNHS PharmacySTANDARD OPERATING PROCEDURES (SOPs)

DTLNHS Pharmacy premi e re!ect the pro"e iona# character o" pharmacy an$ "aci#itate the$e#i%ery o" &ua#ity an$

comprehen i%e pharmaceutica# er%ice 'y the pharmaci t (ithout compromi ing hi or herpro"e iona# )u$gment. Thi premi e (a $e igne$ an$ maintaine$ to meet the patien right an$ nee$ . Moreo%er, the

Pharmaci t ha## 'ere pon i'#e "or the purcha ing, recei%ing, torage, $i tri'ution an$ $i po a# o" $rug in the

Parmacy.

I. Pharmacy Administration

a. The Pharmaci t or the per on $e ignate$ in (riting a re pon i'#e "or the pharmacyi accounta'#e to the Chie" or the e*ecuti%e o+cer, "or proper#y toring an$$i pen ing $rug , recor$ eeping, an$ maintaining a pharmacy po#icy an proce$uremanua#, inc#u$ing comp#aint pri%acy an$ ecurity pro%i ion , an$ en uring #imite$acce into the pharmacy $uring an$ a"ter hour .

'. The Pharmaci t or the per on in charge o" the pharmacy ha## ac&uire, tore,compoun$, an$ $i pen e me$ication accor$ing to app#ica'#e Pharmacy La( an$o' er%e the highe t tan$ar$ o" pro"e iona# practice an$ e ta'#i he$pharmaceutica# proce$ure to en ure the 'e t po i'#e in patient a"ety an$-orpatient me$ication a"ety practice . The Pharmaci t or the per on in charge o" thepharmacy ha## en ure a$e&uate current pharmacy re"erence , har$'oun$ an$-oron#ine acce .

II. Pr scri!tions

a. Pre cription (ritten 'y Me$ica#- Denta# Practitioner ha## 'e ##e$ an$ I" theme$icine pre cri'e$ are not a%ai#a'#e at the pharmacy,the patient may ha%e thepre cription ##e$ out i$e o" the ho pita#.

'. Pre cription ha## 'e per ona#i/e$. I" more than one mem'er o" a "ami#y ipre cri'e$ the ame $rug, a eparate pre cription '#an mu t 'e u e$ "or eachmem'er.

c. Pharmacy ta0 ha## (rite the ##e$ pre cription $etai# uch a manu"acturer1name, #ot num'er, an$ e*piration $ate in the recor$ 'oo .

III. Dis! nsin"

a. The pharmacy ha## er%e a the ource o" upp#y o" re&uire$ pharmaceutica# an$re#ate$ upp#ie . In a$$ition, the pharmacy $i pen e re&uire$, authori/e$preparation $irect#y to patient .

'. 2*cept "or OTC program item , the pharmacy ha## $i pen e a## toc e$ item on#yon recei%ing a proper#y (ritten, %eri e$ pre cription. I" pharmacy ta0 recei%e ani##egi'#e pre cription or &ue tion it authenticity, $o age, compati'i#ity, or $irectionto the patient, ta0 ha## o'tain c#ari cation "rom the pre cri'er 'e"ore $i pen ingthe me$ication3 4.


2/5

c. Thi ho pita# ha## ha%e a y tem 3computeri/e$, (ritten, etc.4 in p#ace to en urethey can o'tain pre cription in ca e o" a pro$uct reca##.

$. Thi ho pita# ha## u'mit a## pertinent patient a$%er e reaction or pro$uct &ua#itypro'#em to 5DA DOH CHD C6.

e. 7hen $i pen ing me$ication, the $i pen er ha## i$enti"y the patient an$ en ure hior her e#igi'i#ity.

". In the e%ent o" a M2DICATION 2RROR 3i.e. an error $i co%ere$ a"ter a pre criptionha 'een $i pen e$ to the patient4, a Me$ication 2rror Report inc#u$ing pertinent

in"ormation re#e%ant to the error 3name o" $i co%erer, $ate o" $i co%ery an$ a 'rie" tatement $e cri'ing error4 ha## 'e comp#ete$.

I#. La$ %in"

a. A #a'e# (i## 'e prepare$ "or each pre cription $i pen e$ to in$i%i$ua# an$ (i## 'eecure#y a+*e$ to the container prior to $i pen ing. The #a'e# or appropriateau*i#iary #a'e#ing (i## ho( a a minimum89. Name o" Pharmacy, inc#u$ing the pharmacy a$$re an$ contact num'er.:. Pre cri'er name.;. De nite, conci e $irection to the patient.


3/5

e. A## purcha e hou#$ 'e recei%e$ 'y "orma# $e#i%ery note c#ear#y $etai#ingE thepro$uct generic name, Fran$ name, &uantity, 'atch Num'er, e*piry $ate an$ othertechnica# peci cation #i e trength, $o age "orm etc. A## $ocument u e$ perprocurement hou#$ 'e proper#y $ate$, ##e$, igne$, tampe$ (ith thepharmaci t? tamp 'earing the name an$ regi tration num'er an$ #e$ in a 'o*#e.

#I. Stora"

a. In torage, eparate e*terna# u e me$ication "rom interna# u e me$ication an$ophtha#mic an$ otic preparation

'. Store !amma'#e $rug accor$ing to accepte$ re a"ety regu#ation .

#II. Pharmacy and Th ra! &tics Committ

a. The committee i an a$%i ory group on a## matter re#ating to the ac&ui ition an$u e o" me$ication . It recommen$ation are u')ect to the appro%a# o" the Chie" o" Ho pita# or the 2*ecuti%e O+cer.

'. The committee i compo e$ o" 'ut not #imite$ to at#ea t one phy ician, one $enti t,pharmaci t an$ repre entati%e "rom me$ica# a$mini tration.

#III. Dis!osa% o' mat ria%s and &i!m nt

a. Appro%e$ 2*piry an$ Near 2*piry tic er hou#$ 'e a%ai#a'#e an$ u e$ in themanner tate$ un$er tan$ar$ "or torage area.

'. There hou#$ 'e egregate$ (a te 'in "or 'ioha/ar$ (a te, ha/ar$ou (a te an$nonha/ar$ou #a'e##e$ in three co#or re$, ye##o( an$ '#ac re pecti%e#y. 5or harp3'io ha/ar$ou (a te4, a harp container hou#$ 'e a%ai#a'#e.

c. Recor$ hou#$ 'e maintaine$ "or $i po a# o" 'io ha/ar$ou an$ ha/ar$ou (a tean$ ne%er $e troye$.

$. Thi Pharmacy ha## e ta'#i h a mechani m o" in"orming c#ient to return e*pire$$rug , unu e$ me$icine , u e$ $rug receptac#e 3'ott#e , %ia# , 'o*e etc4 to thepharmacy premi e .

e. Pharmaceutica# (a te hou#$ 'e c#ear#y i$enti e$ an$ eparate$ "rom u a'#e toc .". The pharmaci t hou#$ en ure that a## the e*i ting #ega# an$ pro"e iona#

re&uirement (ith re pect to the $i po a# o" pharmaceutica# (a te are met.g. The pharmaci t hou#$ en ure that the re#e%ant $ocumentation i comp#ete$ an$

comp#ie (ith #ega# an$ pro"e iona# re&uirement .

I . Prod&cts Com!%aint Hand%in"

a. The re pon i'i#itie $e ne$ in the tan$ar$ SHO LD 'e comp#ie$ (ith at a## time .'. The Ho pita# Pharmacy comp#aint po#icy (hich hou#$ 'e re%ie(e$ "rom time to

time. A## comp#aint ora# or (ritten mu t 'e imme$iate#y a$$re e$ 'y thepharmaci t, an$ uita'#e action 'e ta en to amen$ the ituation.

c. The comp#aint, it nature, the erring per on? name an$ the action ta en mu t 'e$ocumente$ in a comp#aint regi ter.


4/5

$. The e%ent hou#$ 'e re%ie(e$ an$ e%a#uate$ to n$ the un$er#ying cau e3 4.Appropriate tep hou#$ 'e ta en to amen$ the operating proce$ure or othergui$e#ine o a to pre%ent the recurrence o" the ame or imi#ar e%ent .

. Dr&" R ca%%

a. The Pharmaci t hou#$ ha%e a (e## $ocumente$ reca## po#icy.'. The pharmacy hou#$ proacti%e#y participate in any tate (i$e or nation(i$e reca##

proce "or any u' tan$ar$ $rug. A## uch recor$ hou#$ 'e initiate$ uponrecei%ing authentic in"ormation an$ a#arm to $o o. The initiation, progre an$comp#etion o" reca## hou#$ 'e (e## $ocumente$.

c. A$e&uate %igi#ance mu t 'e maintaine$ to #oo out "or reca## a#arm "rom regu#atoryource a (e## a "rom pharmaceutica# companie .

$. In ca e o" any u picion, the pharmaci t hou#$ ta e imme$iate tep to top thea#e o" $rug an$ noti"y the re#e%ant partie .

e. I" the pharmaci t ha a u picion or a rea on to 'e#ie%e that hort coming ha%eoccurre$ in the proce o" $e#i%ery o" me$icine "rom the pharmacy, imme$iatee0ecti%e mea ure hou#$ 'e initiate$ to minimi e the ri o" $amage or $anger tothe patient3 4.

I. Co%d Chain *ana" m nt

a. The Pharmaci t an$ Pharmacy ta0 ha## en ure that the vaccines they dispense have beencorrectly stored.

b. The refrigerator for storage of biologicals should be specifically designed for this purpose and shouldhave a lock.

c. 6accine are en iti%e 'io#ogica# pro$uct E protection o" %accine potency an$ta'i#ity i important. The recommen$e$ temperature "or %accine torage i , at a##time , :JC to JC.

d. A## 'io#ogica# pro$uct "ree/e at temperature 'e#o( KCE pro$uct that ha%e 'eene*po e$ to temperature 'e#o( KC hou#$ not 'e u e$.

e. A temperature monitoring y tem ha## 'e p#ace$ in the re"rigerator an$ ca#i'rate$"rom time to time.

f. A coo# pac - 'o* mu t 'e u e$ in tran porting 'io#ogica# .g. A## ac&uire$ 'io#ogica# ha## 'e recor$e$ proper#y 'y the Pharmaci t or the

Pharmacy ta0.

II. Ad+ rs Dr&" R action

a. The Pharmaci t ha## out#ine a tep 'y tep approach "or emp#oying the

pontaneou reporting o" a$%er e $rug reaction in monitoring me$icine a"ety "oru e.'. In ca e o" ADR reporte$ 'y patient , the Pharmaci t ha## ## out the reporting "orm

an$ u'mit it to 5DA.c. The reporting "orm hou#$ 'e imp#e an$ ea y to comp#ete. The reporting

"orm hou#$ not re&ue t too much in"ormation, particu#ar#y in"ormation thati $i+cu#t to n$ an$ recor$, or in"ormation that i un#i e#y to 'e u e$.

$. The reporting "orm hou#$ ha%e u+cient pace in (hich to $e cri'e theu pecte$ reaction3 4. The "orm hou#$ carry a tatement rea uring

con $entia#ity o" in"ormation gi%en


5/5

e. The report hou#$ 'e tore$ ecure#y to maintain pri%acy.". ADR Report ha## inc#u$e e entia# $ata e#ement , $etai# o" me$icine ,

reaction $etai# , reporter $etai# , a$%i e to reporter an$ report "o##o( up.

Appro%e$ 'y8 Date8

standard operating procedures hospital

Documents