84-14 Pharmacy and therapeutics committee

 The pharmacy and therapeutics and drug utilization committee shall be appointed in conformity with these bylaws and have representation from medical staff, nursing, pharmacy department, and hospital administration. The majority of members shall be members of the medical staff. The committee shall meet at least quarterly and carry out the following duties:

(A)  Review the appropriateness, safety, and effectiveness of the prophylactic, empiric, and therapeutic use of drugs, including antibiotics, through the analysis of individual or aggregate patterns of drug practice.

(B)  Provide the medical and hospitals staff with information and advice concerning the proper use of drugs and related products. Monitor and evaluate those drugs which are most prescribed, known to present problems or risks to patients, and which constitute a critical part of a patient's specific diagnosis, condition or procedure.

(C)  Consider the welfare of patients as well as education, research and economic factors when analyzing the utilization of drugs and related products.

(D)  Advise on the use and control of experimental drugs.

(E)  Develop or approve policies and procedures relating to the selection, distribution, use, handling, and administration of drugs and diagnostic testing materials.

(F)  Review all significant untoward drug reactions.

(G)  Maintain the Formulary of Accepted Drugs with review of proposed additions and deletions and review of use of non-formulary drugs within the institution.

(H)  Maintain written reports of conclusions, recommendations, actions taken, and the results of actions taken, and report these at least quarterly to the medical staff administrative committee.

(I)  Create sub-committees, as follows: pharmacy and therapeutic and drug utilization executive sub-committee; formulary sub-committee; antibiotic usage sub-committee; medical safety and policy sub-committee; and the therapeutic drug monitoring sub-committee.

(J)  The therapeutic drug utilization monitoring sub-committee shall:

  1. Establish methods by which serum blood levels may be used to improve the therapeutic activity of drugs.
  2. Establish programs to educate health care providers to the appropriate methods of monitoring the therapeutic effect in drugs via serum drug assays.
  3. Provide guidance to the therapeutic drug monitoring service at university hospitals.
  4. Recommend the development of policies and procedures to the pharmacy and therapeutic and drug utilization executive sub-committee.

(Board approval dates: 4/7/2000, 9/6/2002, 4/6/2016)