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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