TRUST POLICY FOR PRODUCTION OF
DRUG THERAPY GUIDELINES
Version
6
Name of responsible (ratifying) committee
Formulary & Medicines Group
Date ratified
18th July 2014
Document Manager (job title)
Guidelines Pharmacist
Date issued
07th August 2014
Review date
06th August 2016
Electronic location
Clinical Policies
Related Procedural Documents
Key Words (to aid with searching)
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
6
18.07.2014
No content changes. Layout and spelling corrections only.
M. Bennett-Marsden
5
18.1.2013
Updated to reflect new guidelines pharmacist role/s
M. Bennett-Marsden
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 1 of 6
CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1. INTRODUCTION.......................................................................................................................... 3
2. PURPOSE ................................................................................................................................... 3
3. SCOPE ........................................................................................................................................ 3
4. DEFINITIONS .............................................................................................................................. 3
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 3
6. PROCESS ................................................................................................................................... 4
7. TRAINING REQUIREMENTS ...................................................................................................... 4
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 4
9. EQUALITY IMPACT STATEMENT .............................................................................................. 5
10. MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY ......................... 5
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 2 of 6
QUICK REFERENCE GUIDE
This policy describes the process for the preparation, approval, publication, audit and review of
Portsmouth Hospitals NHS Trust Drug Therapy Guidelines.
1. Drug Therapy Guidelines are developed in order to improve patient safety and limit risk by
provision of concise, structured, evidence-based clinical and pharmaceutical information on a
range of medicines management topics relevant to the treatment of patients under the care of
practitioners working for Portsmouth Hospitals NHS Trust.
2. Information on relevant adverse incidents will be reported to the specified Guideline Project
Manager for action and will be considered in the production of new or revised Drug Therapy
Guidelines.
This does not negate the need for the document author and others involved in the process to be
aware of and follow the detail of this policy.
1. INTRODUCTION
The Policy for the Production of Drug Therapy Guidelines covers the processes involved in the
preparation, approval, publishing, audit and review of Portsmouth Hospitals NHS Trust Drug
Therapy Guidelines.
2. PURPOSE
The purpose of this policy is to ensure the consistent preparation, approval, publishing, audit
and review of Drug Therapy Guidelines.
3. SCOPE
This policy applies to all Portsmouth Hospitals NHS Trust staff involved with the preparation of
Drug Therapy Guidelines.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Drug Therapy Guidelines: Guidance documents prepared to assist healthcare staff in the safe
prescribing, preparation, control and administration of medicines for specific clinical conditions.
5. DUTIES AND RESPONSIBILITIES
Guideline Project Manager
A member of pharmacy staff will be designated by the Clinical Pharmacy Manager to manage
the process of development of a Drug Therapy Guideline, including establishing and leading a
Guideline Development Group and ensuring that the requirements of this policy are adhered to.
Guideline Development Group
A group will be established by the Guideline Project Manager to develop the content of the
proposed Drug Therapy Guideline including review of evidence and undertaking consultation
with intended users of the guideline and other relevant stakeholders. The Guideline
Development Group should be multidisciplinary and include members with experience and
expertise in the relevant area.
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 3 of 6
Ratifying body
The PHT Formulary and Medicines Group will be responsible for the approval of Drug Therapy
Guidelines. The Guideline Project Manager will submit the draft Drug Therapy Guideline
together with the completed form PHPS07001 (see below) detailing the process of
development, consultation and preparation of the guideline.
The Formulary and Medicines Group will check that the draft Drug Therapy Guideline
• is based on the best available evidence and is technically accurate
• is not discriminatory along the adult age continuum, unless there is clear evidence for agedefined contra-indication and this is recorded.
• is discriminatory for paediatrics if appropriate;
• has undergone multi-disciplinary consultation with the relevant stakeholders
The Formulary and Medicines Group will record ratification of the Drug Therapy Guidelines in
the meeting notes, together with any conditions e.g. agreed minor amendments to be made
prior to publication. If more than minor changes are required the Formulary and Medicines
Group may request that a revised draft is presented to the committee for ratification. The
required amendments will be documented in the meeting notes.
The development, ratification and publication of all other Trust procedural documents is
detailed in the Trust Procedural Documents Development and Management Policy.
6. PROCESS
The actions to be taken to comply with this policy are described in PHPS Work Instruction
PHPSWI07001
All Drug Therapy Guidelines will follow the format specified in this Work Instruction.
The Guideline Project Manager will document the development of the Drug Therapy Guideline
on form PHPSF07001 including the sources of information and all references used and the
methods used to interpret and assess the strength of evidence for the key recommendations.
In particular there should be an explicit link between major recommendations and the level of
supporting evidence.
The methods used to formulate the recommendations will be documented including how the
views of stakeholders not on the Guideline Development Group were taken into account.
An equality impact assessment will be carried out and documented in PHPSF07001
Following ratification by the Formulary and Medicines Group the Guideline Project Manager will
make any necessary amendments and prepare a final version ready for publishing. This will be
passed to the guidelines pharmacist for publishing on the intranet in accordance with PSWI021.
7. TRAINING REQUIREMENTS
All personnel involved in the development, ratification and publication of Drug Therapy
Guidelines must be aware of this policy.
There are no specific training requirements.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Portsmouth Hospitals NHS Trust Procedural Documents Development and Management
Policy.
Portsmouth Hospitals Pharmacy Service Work Instruction PHPSWI07001
Portsmouth Hospitals Pharmacy Service Form PHPSF07001
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 4 of 6
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
10. MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY
The Formulary and Medicines Group will ensure that any Drug Therapy Guidelines submitted
for ratification comply with the requirements of this policy and may refuse to approve the
publication of any Drug Therapy Guidelines that have not been developed in accordance with
this policy. The Formulary and Medicines Group will require the submission of PHPSF07001
together with the draft guideline to provide assurance that the Drug Therapy Guideline has
been developed (or reviewed, in the case of previously published Drug Therapy Guidelines) in
line with this policy.
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 5 of 6
Appendix 1
Drug Therapy Guideline Template
(Renal/Paed*) Drug Therapy Guideline No Issued: date posted on intranet
TITLE
Subject (alphabetical search)
Introduction
This guidance supports
The objectives of this guideline are
This guideline applies to all (specify any restrictions to patient group) patients under
the care of practitioners working for Portsmouth Hospitals NHS Trust.
Recommendations
Subheading
Subheading
Content text …
Key References
Evidence Base
Name, Post manages this guideline (ext XXXX)
See Trust Policy for the Production of Drug Therapy Guidelines
Approved by: Formulary & Medicines Group
Review date: (+2yrs unless otherwise stated)
Date
Page x of y
Control date: insert date that rolls over each day
Trust policy for the production of drug therapy guidelines: Version 6
Review date: 06/08/2016
Issue Date: 07/08/2014
Page 6 of 6