C3.2 R3: Prepare and dispense medications according to organizational policies and procedures

Throughout the rotation, I had the opportunity to be involved with handling orders for non-formulary medications. (For excluded medications, the majority of them are able to be auto-subbed as per the policy: automatic-therapeutic-interchange-adult-patients).

Non-formulary medications are medications where no decision has been made on whether it should be on the formulary, or are restricted drugs that have not met the restriction criteria. For non-formulary and excluded drugs to be started/continued in the hospital, they need to meet the following criteria based on the policy:

  • Efficacy and safety is supported by evidence
  • Drug is clinically appropriate for patient
  • No acceptable formulary alternatives
  • For excluded drugs, use should be limited to exceptional circumstances around patient-specific factors only

If patients were on a non-formulary medication PTA and the above criteria are met, pharmacy will try to coordinate so that patient can use patient’s own medications (POM). For POMs that are scheduled daily and not OTCs, they will be flagged and pharmacy technicians will follow up and check if patients have their own supply. If they have their own supply, it will be brought back to the pharmacy for identification and verification.

If patients cannot supply or supply is not considered usable (e.g. a low hazardous drug, blister packed medications) and cannot be held during hospital stay, the pharmacist will fill out a “Non-Formulary and Excluded Drug Approval Form”. If cost per day < $100, the dispensary supervisor can approve it and if >$100, the clinical coordinator can approve it. Ordering the supply of non-formulary drugs is the same process for formulary drugs.


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