Section 250.2140  Pharmacy and Therapeutics Committee

a)         In accordance with the bylaws, rules and regulations of the medical staff, an interdisciplinary committee acceptable to the Board shall be appointed to assure the responsibility for the functions of the service.

b)         The committee shall meet not less than quarterly and record minutes of their meetings, which shall reflect their activities.

c)         The functions of the committee shall include but not be limited to the following:

1)         formulate rules and regulations relating to the selection, evaluation, distribution, and administration of drugs and biologicals in the hospital;

2)         establish control and reporting procedures for the use of investigational (experimental, trial use) drugs and biologicals;

3)         promote educational programs relating to drug interactions and information on drug therapy, side effects, toxicology, dosage, indications for use and route of administration to the professional staff;

4)         develop and update the Service Policy and Procedure Manual, the Hospital Formulary or Drug List;

5)         review and act on recommendations, drug usage reports, medication error and/or other incident reports, storage, distribution and administration of drugs;

6)         to develop policies and procedures (which shall be approved by the Medical Staff and Board) to provide for the administration of identified drugs and medicines by qualified professional persons who are authorized by law to administer such drugs and biologicals in the course of practicing their professions; and

7)         establish the guidelines for the education, in-service training and supervision of all personnel administering drugs and biologicals.

(Source:  Amended at 49 Ill. Reg. 14395, effective October 27, 2025)