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INFECTION CONTROL POLICY

GUIDELINES

Document No.
IFH-InfectionControl 2015-014

PHARMACY DEPARTMENT

Page No.
Page 1 of 5

IMUS FAMILY HOSPITAL


INFECTION CONTROL GUIDELINES
PHARMACY DEPARTMENT

1.0

OBJECTIVE:
1.1

To provide a formal documentary program for the Infection Control Program

for Pharmacy Department.


1.2

To ensure that the activities are conducted in a manner that will comply with

the current standards and guidelines for operation relative to infection control.
1.3

To ensure that the Pharmacy Department has formalized documented

procedures to ensure that these policies and procedures are in accordance with
pertinent standards and guidelines to initiate action to improve or update them
as needed.
1.4

To ensure that the Pharmacist have a clear responsibilities to participate in

infection control program.


1.5 To conduct education and training particularly from their understanding and
influence over rational
use of antibiotic in the hospital
1.6

1.7

2.0

The Pharmacists responsibilities extend to the following areas:


a.

The control of nosocomial infection

b.

Promotion of the rational use of antimicrobial agents

c.

Education

To strictly implement and follow the rules and regulations.

SCOPE:

INFECTION CONTROL POLICY


GUIDELINES

Document No.
IFH-InfectionControl 2015-014

PHARMACY DEPARTMENT

Page No.
Page 2 of 5

This procedure applies for Infection Control Policy for Pharmacy Department
3.0

RESPONSIBILITY:

Chairman - Infection Control Committee


Co-Chairman Infection Control Committee
Pharmacist
Members
4.0

PROCEDURES:

4.1 Control of Nosocomial Infection


a. Participate in the affairs of Infection Control Committee/Program.
b. Advise the hospital in the selection and use of appropriate antiseptic,
disinfectant and sterilizers.
c. Establish pharmacy policies, procedures and clear guidelines for pharmacy staff
on the correct
procedures for proper handling and storage of drugs.
d. All equipment and utensils such as trays and spatulas utilized during the
course of a workday are to
be thoroughly cleaned immediately after use.
e. Disinfect the work surfaces and all accessible surfaces with approved
disinfectant before beginning
work
f. Establish the personnel policies (e.g. limiting the activities of staff/members who
exhibit symptoms
of colds, flu and other infectious condition.)
g. Encourage the use of single use packages of sterile drugs instead of multiple
dose containers.
h. Recommend the proper storage of sterile and reconstituted products and
multiple dose containers

INFECTION CONTROL POLICY


GUIDELINES

Document No.
IFH-InfectionControl 2015-014

PHARMACY DEPARTMENT

Page No.
Page 3 of 5

(if used)
4.2 Promotion of Rational Use of Antimicrobial Agents
This responsibility extends to the establishment of measures for minimizing the
development of resistant strains of microorganism as well as maximizing the
chance of successful therapeutic outcomes in individual patients. Functions related
to this responsibility include the following:
a. Work within the PTC structure to control the number and types of antibiotics and
other antimicrobial agents. Both therapeutic and microbiological factors and
cost-containment considerations should justify such decisions.
b. Collaborate with the medical staff in establishing policies related to prophylactic
antibiotic use, restricted use of specific antibiotic and other microbial agents.
c. Establish and operate (in coordination with the medical staff) an ongoing
concurrent prospective antibiotic use review program or assessing and
improving the quality of antimicrobial therapy.
d. Generate and analyze quantitative data on antimicrobial drug use.
e. Work with the concerned individuals and committees within the institution
responsible for selecting and controlling IV sets, infusion devices and other
equipment related to IV and antibiotic administration.
4.3 Educational Activities
This responsibility extends to other professionals, patients and the public. Specific
functions include the following:
a. Conduct in-service educational programs, clinical conferences and other types
of presentations for health professionals on appropriate topics including (but not
limited to) the following:
1. Antimicrobial therapy
2. Decontaminating agents (disinfectant, antiseptic, sterilizers)
3. Aseptic technique procedures and procedures

INFECTION CONTROL POLICY


GUIDELINES

Document No.
IFH-InfectionControl 2015-014

PHARMACY DEPARTMENT

Page No.
Page 4 of 5

4. Sterilization methods
b. Educational and counseling in-patients, ambulatory care patients in the
following areas:
1. Importance of compliance with prescribed directions for antibiotics and other
drugs.
2. Other information necessary for safe and appropriate drug use (e.g. whether
or not to take drugs with meals)
3. Instruction on storage conditions, including drug administered through home
care programs.
4. Other infection control proc
c. Establish and conduct ongoing quality assurance activities and in-service
presentations to pharmacy staff on appropriate topics including but not limited
to:
1. Aseptic techniques and procedures
2. Sterilization methods
d. Participate in public health education and awareness campaign concerning
control of the spread of infectious diseases
5.0 QUALITY OF RECORDS
5.1

All activities of Infection Control Policy committee should be documented for

proper implementation purposes.

6.0

End of Document
Prepared by:

Reviewed and Approved by:

Leonor C. Caguiat, M.D.

Ofelia P. Luceo, M.D.

Date: February 16, 2015

Date: February 16, 2015

Revision
0
Issue No.:
1

INFECTION CONTROL POLICY


GUIDELINES

Document No.
IFH-InfectionControl 2015-014

PHARMACY DEPARTMENT

Page No.
Page 5 of 5

Date Issued:
February 20, 2015

Date Effective:
February 20, 2015

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