e.
f.
g.
h.
Develop procedures and systems for identifying, reporting, and analyzing the incidence and causes of infections;
Institute any surveillance, prevention, and control measures or studies when there is reason to believe any patient or personnel may be at risk;
Report healthcare acquired infection findings to the attending physician and appropriate clinical or administrative leader; and
Review all policies and procedures on infection prevention, surveillance, and control at least biennially.
1.2.10 Pharmacy and Therapeutics Functions a. Maintain a formulary of drugs approved for use by the Hospital; b.
c.
Create treatment guidelines and protocols in cooperation with medical and nursing staff including review of clinical and prophylactic use of antibiotics;
Monitor and evaluate the efforts to minimize drug misadventures( adverse drug reactions, medication errors, drug / drug interactions, drug / food interactions, pharmacist interventions);
d. Perform drug usage evaluation studies on selected topics; e. Perform medication usage evaluation studies as required by The Joint Commission; f. Perform practitioner analysis related to medication use; g.
h.
Approve policies and procedures related to The Joint Commission Patient Care Standards: to include the review of nutrition policies and practices, including guidelines / protocols on the use of special diets and total parenteral nutrition; pain management; procurement; storage; distribution; use; safety procedures; and other matters relating to medication use within the Hospital;
Develop and measure indicators for the following elements of the patient treatment functions:
i. Prescribing / ordering of medications; ii. Preparing and dispensing of medications; iii.
Administrating medications; and iv. Monitoring of the effects of medication;
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