(a)  A pharmacy committee or its equivalent, to include physicians, registered nurses, pharmacists and the administrator or designee shall be established.

(b)  The committee shall meet at least quarterly, record its proceedings and report to the medical staff. It shall assist in the formulation of broad professional policies regarding the evaluation, appraisal, selection, procurement, storage, distribution, use and safety procedures, and all other matters relating to drugs in the facility. This shall include a mechanism to review and evaluate adverse drug reactions and drug usage evaluations, offering appropriate recommendations, actions, and follow-up if necessary. The committee shall:

(1)           serve as an advisory group to the medical staff and the pharmacy director on matters pertaining to drug selection;

(2)           develop an ongoing mechanism to review a formulary or drug list for use in the hospital;

(3)           recommend and develop policies regarding the use and control of investigational drugs and research in the use of U.S. Food and Drug Administration approved drugs;

(4)           evaluate clinical data concerning new drugs or preparations requested for use in the facility;

(5)           make recommendations concerning drugs to be stocked on the nursing units and by other services;

(6)           establish mechanisms which will prevent formulary duplication;

(7)           establish policies and procedures that address therapeutic drug substitution;

(8)           establish a policy describing the duration of drug therapy or number of doses for all medication orders; and

(9)           make recommendations regarding medication administration policies and procedures.


History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.