Department
of Pharmacy Policies & Procedures
Number: 5:18
Effective Date: October,
1987
Revisions: 4/93; 5/00;
10/09
Approval:
Subject: NON-FORMULARY
DRUG ORDERS
A. POLICY
The UAMS Medical Center uses
the formulary system to determine the availability of drug for patient use. The
formulary is a controlled listing of these drugs. Occasionally the professional
staff may order a drug for inpatient use which is not contained in the
formulary. Under the provisions stated herein, such drug items can be obtained
and dispensed by the hospital pharmacy.
B. PROCEDURE
1. The physician's order for
a non-formulary drug is received in the pharmacy.
2. The pharmacist checks the
physician name against the attendingand housestaff list. Only attending physicians have the privilege
of ordering a non-formulary drug.
3. The Sunrise order pathway
informs the ordering physician of procedures to follow to order a non-formulary
drug. The reason for use of the drug must be documented and the need for the
drug must be verified by an attending physician through the computer system or by telephone to
the pharmacy.
a.
If the prescriber is a housestaff physician, the
order must be verified by an attending physician. Until this occurs, no action
will be taken. The pharmacist will suspend the order within
the computer system and
document the reason as “Pending Attending Physician Authorization”. The
pharmacist may, however, wish to locate a source for the drug.
b.
If the prescriber is an attending physician
or if authorization is received by an attending physician, the pharmacist
should obtain the smallest quantity of the drug needed, consistent with the
dose and expected duration of use. After
the drug has been obtained, if the order has been suspended in
the computer system, the
pharmacist will unsuspend the order and document the
reason as “Attending Physician Authorization Received”.
4. There will be a stocking
fee charged for any non-formulary drug obtained and dispensed.
5. In the outpatient
pharmacy, non-formulary drugs will be purchased and dispensed only to employees
of UAMS.