THE PHARMACY TECHNICIAN, THE P&T COMMITTEE and THE HOSPITAL FORMULARY
Pharmacy Technicians and the Pharmacy and Therapeutics Committee
Technicians are considered medication distribution experts whereas Pharmacists are understood as medication use experts. So, at this time the role of a Pharmacy Technician on the P & T Committee is limited or non-existent. Participation may include clerical duties (e.g. booking or recording the meeting) or being able to attend as a non-voting member. The Canadian Agency for Drugs and Technology in Health (CADTH) provides a recent report on P & T Committees in hospitals across Canada. In it, information regarding membership and roles and responsibilities can be found.
Patient Care and the Formulary System
Care of patients in hospitals and other health-care facilities is dependent upon the effective use of drugs. Because a multiplicity of drugs are available it is essential that a sound program of drug usage be developed within the institution. This helps ensure that patients receive the best possible care.
Formulary System
In the interest of patient care, the institution (hospital) should have in place a program of objective evaluation to oversee the selection and use of medicinal agents in the facility. The Formulary System is a program which provides the basis for appropriate and economical drug therapy whereby medical staff, working through the P & T committee, evaluates, appraises, and selects those drugs that are considered the most useful in patient care. Only those drugs selected are routinely available. The system is an important tool for assuring the quality of drug use and in controlling its cost.
Hospital Formulary
A Hospital Formulary is an up-to-date listing of pharmaceuticals, information and policies approved for use within the institution, which reflect the current clinical judgment of the hospital’s medical and pharmacy staff. It is more than just a drug list. It contains Information on formulary use/drug control, guidelines and tables of drug treatments, Therapeutic Interchanges, a cross-index of non-proprietary and brand names, drug distribution policies and procedures and prescribing regulations within the hospital.
Formulary Drug
A formulary drug is a therapeutic agent whose place in therapy is well established. It is an agent selected by the P & T Committee as being essential for best patient care. Efforts are made to ensure that formulary drugs are stocked in the pharmacy at all times to prevent delay in therapy.
Formulary Effectiveness
A Hospital Formulary must have the approval of an organized medical staff and agreement of individual staff members. A fully functioning and properly organized P & T (or D & T) committee is required to ensure that the formulary remains effective and up-to-date. Basic policies and procedures governing the formulary system should be incorporated into the medical staff bylaws or rules and regulations.
Pharmacy and Therapeutics Committee and the Formulary
The P & T Committee assists in formulating professional policies relating to drugs including their evaluation or appraisal, selections and procurement, storage and distribution and safe use. The P & T Committee is responsible to the medical staff. Recommendations from the Committee are subject to approval by the medical staff and the normal approval process.
Benefits of a Formulary
The Formulary offers three main benefits: Therapeutic, Economic, and Educational.
Therapeutic Benefit - The Formulary offers the greatest benefit to the patient and physician because the most effective and cost efficient products are listed and therefore available. The research has already been done to select the most effective drugs and include them in the formulary.
Economic Benefit - The Formulary eliminates duplication, reducing inventory duplication and increasing the opportunity for volume purchasing (e.g. including only HCTZ 50 mg – 25 mg dose would require ½ tablets).
Educational Benefit - The Formulary contains information for prescribing and drug use in addition to a listing of drugs. For example the formula for calculating BSA may be provided.
Formulary Content and Organization
The primary objectives of the formulary are to provide Information on drug products approved for use, basic therapeutic information, Information on policies and procedures governing use of drugs and 'special' information about drugs (e.g. dosing guidelines, nomograms, approved abbreviations, sodium content of drugs).
Main parts of the Formulary (3)
In accordance with the objectives, the formulary should consist of 1. Information on Organizational Policies and Procedures Concerning Drugs, 2. a List of Drug Products and 3. Special Information.
1. Information on Organizational Policies and Procedures Concerning Drugs: Information such as regulations governing prescribing, dispensing and administration of drugs, prescribing, dispensing and administering of drugs, writing drug orders, approved abbreviations, Narcotic and Controlled Drug considerations, generic/therapeutic substitution policies, Automatic Stop Orders, Patient’s use of own medications and self-administration, Stat or Emergency drug orders, Emergency carts and kits, drug administration times, ADRs and medication errors and use of floor stock items may be included in this section.
2. Drug Products List: Type of information in each entry will vary. At minimum, each entry must include the Generic name, common brand name, dosage forms, strengths, packaging, size stocked by pharmacy, formulation (active ingredients) of a combination product and AHFS-DI category number.
3. Special Information: Content may include information on Nutritional products, a Table of equivalent dose of similar drugs, a List of sugar-free products, Standard TPN formula and Guide for calculating pediatric dosages, Contents of ER carts, Pharmacokinetic dosing and monitoring, Metric conversion tables and forms, Drug interactions, injectable drug incompatibilities, Poison control centre, Dosages, concentrations, standard dilutions and Electrolyte content of LVPs.
American Hospital Formulary System Drug Information (AHFS-DI)
AHFS is a system used to classify drugs in North America. It consists of a 6 digit number which is used to indicate the broad therapeutic class and sub-therapeutic classes and categories of particular drugs. For example the ODB e-formulary classifies Lipitor as "24:06:00 Antilipemic Drugs" as its sub-therapeutic class. What is the broad therapeutic class for Lipitor according to ODB?
Format and Appearance
There is no single format or arrangement of a Hospital Formulary. A typical formulary might have a Title page, Table of Contents, List of Drug Products and an Appendix. Several techniques can improve the appearance and ease of use for print copies (e.g. Different paper colour for each section, Edge index, Pocket size; Printing the generic name in boldface to make it stand out).
Copies of the Formulary (or electronic access)
Access to the Hospital Formulary should be made available to all members of the Pharmacy department, including those working in satellite pharmacies and on-call pharmacists. Print copies or electronic access should also be available to healthcare workers in patient care areas (including the night cupboard), the medical library, physician board rooms, administration (Nursing) areas, and active medical staff members.
Formulary Authority
Any brand of medication with the same generic name as that prescribed can be dispensed (e.g. Apo-Atorvastatin for Lipitor). Selecting the brand to be used in the hospital is the pharmacy’s prerogative. As in a community pharmacy the manufacturer or supplier may change at any time. A physician may request that a certain brand be dispensed for a particular patient (e.g. due to sensitivities/allergies to different non-drug components). A process will be in place to deal with such a situation.
CHECKPOINT Question ONE: The ODB Formulary makes use of the AHFS-DI Therapeutic Classifications system. Compare the ODB Formulary to the online formulary available for the Vancouver Coastal Health Authority. Does it appear that the VCH follows the same format of AHFS-DI classification? What other information is available in their Formulary? What types of policies and procedures are included?
Pharmacy Technicians and the Pharmacy and Therapeutics Committee
Technicians are considered medication distribution experts whereas Pharmacists are understood as medication use experts. So, at this time the role of a Pharmacy Technician on the P & T Committee is limited or non-existent. Participation may include clerical duties (e.g. booking or recording the meeting) or being able to attend as a non-voting member. The Canadian Agency for Drugs and Technology in Health (CADTH) provides a recent report on P & T Committees in hospitals across Canada. In it, information regarding membership and roles and responsibilities can be found.
Patient Care and the Formulary System
Care of patients in hospitals and other health-care facilities is dependent upon the effective use of drugs. Because a multiplicity of drugs are available it is essential that a sound program of drug usage be developed within the institution. This helps ensure that patients receive the best possible care.
Formulary System
In the interest of patient care, the institution (hospital) should have in place a program of objective evaluation to oversee the selection and use of medicinal agents in the facility. The Formulary System is a program which provides the basis for appropriate and economical drug therapy whereby medical staff, working through the P & T committee, evaluates, appraises, and selects those drugs that are considered the most useful in patient care. Only those drugs selected are routinely available. The system is an important tool for assuring the quality of drug use and in controlling its cost.
Hospital Formulary
A Hospital Formulary is an up-to-date listing of pharmaceuticals, information and policies approved for use within the institution, which reflect the current clinical judgment of the hospital’s medical and pharmacy staff. It is more than just a drug list. It contains Information on formulary use/drug control, guidelines and tables of drug treatments, Therapeutic Interchanges, a cross-index of non-proprietary and brand names, drug distribution policies and procedures and prescribing regulations within the hospital.
Formulary Drug
A formulary drug is a therapeutic agent whose place in therapy is well established. It is an agent selected by the P & T Committee as being essential for best patient care. Efforts are made to ensure that formulary drugs are stocked in the pharmacy at all times to prevent delay in therapy.
Formulary Effectiveness
A Hospital Formulary must have the approval of an organized medical staff and agreement of individual staff members. A fully functioning and properly organized P & T (or D & T) committee is required to ensure that the formulary remains effective and up-to-date. Basic policies and procedures governing the formulary system should be incorporated into the medical staff bylaws or rules and regulations.
Pharmacy and Therapeutics Committee and the Formulary
The P & T Committee assists in formulating professional policies relating to drugs including their evaluation or appraisal, selections and procurement, storage and distribution and safe use. The P & T Committee is responsible to the medical staff. Recommendations from the Committee are subject to approval by the medical staff and the normal approval process.
Benefits of a Formulary
The Formulary offers three main benefits: Therapeutic, Economic, and Educational.
Therapeutic Benefit - The Formulary offers the greatest benefit to the patient and physician because the most effective and cost efficient products are listed and therefore available. The research has already been done to select the most effective drugs and include them in the formulary.
Economic Benefit - The Formulary eliminates duplication, reducing inventory duplication and increasing the opportunity for volume purchasing (e.g. including only HCTZ 50 mg – 25 mg dose would require ½ tablets).
Educational Benefit - The Formulary contains information for prescribing and drug use in addition to a listing of drugs. For example the formula for calculating BSA may be provided.
Formulary Content and Organization
The primary objectives of the formulary are to provide Information on drug products approved for use, basic therapeutic information, Information on policies and procedures governing use of drugs and 'special' information about drugs (e.g. dosing guidelines, nomograms, approved abbreviations, sodium content of drugs).
Main parts of the Formulary (3)
In accordance with the objectives, the formulary should consist of 1. Information on Organizational Policies and Procedures Concerning Drugs, 2. a List of Drug Products and 3. Special Information.
1. Information on Organizational Policies and Procedures Concerning Drugs: Information such as regulations governing prescribing, dispensing and administration of drugs, prescribing, dispensing and administering of drugs, writing drug orders, approved abbreviations, Narcotic and Controlled Drug considerations, generic/therapeutic substitution policies, Automatic Stop Orders, Patient’s use of own medications and self-administration, Stat or Emergency drug orders, Emergency carts and kits, drug administration times, ADRs and medication errors and use of floor stock items may be included in this section.
2. Drug Products List: Type of information in each entry will vary. At minimum, each entry must include the Generic name, common brand name, dosage forms, strengths, packaging, size stocked by pharmacy, formulation (active ingredients) of a combination product and AHFS-DI category number.
3. Special Information: Content may include information on Nutritional products, a Table of equivalent dose of similar drugs, a List of sugar-free products, Standard TPN formula and Guide for calculating pediatric dosages, Contents of ER carts, Pharmacokinetic dosing and monitoring, Metric conversion tables and forms, Drug interactions, injectable drug incompatibilities, Poison control centre, Dosages, concentrations, standard dilutions and Electrolyte content of LVPs.
American Hospital Formulary System Drug Information (AHFS-DI)
AHFS is a system used to classify drugs in North America. It consists of a 6 digit number which is used to indicate the broad therapeutic class and sub-therapeutic classes and categories of particular drugs. For example the ODB e-formulary classifies Lipitor as "24:06:00 Antilipemic Drugs" as its sub-therapeutic class. What is the broad therapeutic class for Lipitor according to ODB?
Format and Appearance
There is no single format or arrangement of a Hospital Formulary. A typical formulary might have a Title page, Table of Contents, List of Drug Products and an Appendix. Several techniques can improve the appearance and ease of use for print copies (e.g. Different paper colour for each section, Edge index, Pocket size; Printing the generic name in boldface to make it stand out).
Copies of the Formulary (or electronic access)
Access to the Hospital Formulary should be made available to all members of the Pharmacy department, including those working in satellite pharmacies and on-call pharmacists. Print copies or electronic access should also be available to healthcare workers in patient care areas (including the night cupboard), the medical library, physician board rooms, administration (Nursing) areas, and active medical staff members.
Formulary Authority
Any brand of medication with the same generic name as that prescribed can be dispensed (e.g. Apo-Atorvastatin for Lipitor). Selecting the brand to be used in the hospital is the pharmacy’s prerogative. As in a community pharmacy the manufacturer or supplier may change at any time. A physician may request that a certain brand be dispensed for a particular patient (e.g. due to sensitivities/allergies to different non-drug components). A process will be in place to deal with such a situation.
CHECKPOINT Question ONE: The ODB Formulary makes use of the AHFS-DI Therapeutic Classifications system. Compare the ODB Formulary to the online formulary available for the Vancouver Coastal Health Authority. Does it appear that the VCH follows the same format of AHFS-DI classification? What other information is available in their Formulary? What types of policies and procedures are included?