ILOILO CITY HEALTH OFFICE

2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

INSTITUTIONAL PHARMACY OPERATIONAL MANUAL

1st Edition

Table of Contents
202
3
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

CONTENT
Vision & Mission
Core Values
Pharmacist in Public Health (Roles, Duties and
Responsibilities)
Pharmacist Daily Routine Task Checklist
Requirements for Institutional Pharmacies
POLICY POLICY TITLE
NUMBE
R
SCM-01-00- Good Housekeeping
R0
SCM-02-00- Professional Standards for Dispensaries, Medicine
R0 Rooms, and Medical Supply Storage
SCM-03-00- Cold Chain Receiving, Storage Monitoring and
R0 Preventive Measures
SCM-04-00- Pest Control in the Dispensaries, Medicine
R0 Rooms, and Medical Supply Storage Areas
SCM-05-00- Daily Routine and Working Hours
R0
SCM-06-00- Reporting and Handling Adverse Drug Reactions
R0
SCM-07-00- Good Dispensing Practice Practices and
R0 Evaluation of Prescription Errors
SCM-08-00- Regulations for Drug Dispensing
R0
SCM-09-00- Drug Quality Report
R0
SCM-10-00- Medication Error & Near Miss Reporting
R0
SCM-11-00- Inventory Control
R0
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

SCM-12-00- Look-a-like, Sound-a-Like

R0
SCM-13-00- Procurement of Stocks and Proposal
R0
SCM-14-00- Reverse Logistics: Product Recall
R0
SCM-15-00- Waste Management
R0
SCM-16-00- Emergency Protocol Plan
R0
Risk Management Plan

VISION
A globally competitive
high–performing pharmaceutical
services that focuses in the field
of Public Health for every
Ilonggo in 2028.

MISSION
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Ensure equitable access in

delivering quality, safe and
effective pharmaceutical
products and efficient
pharmacy services in all areas of
Iloilo City.

PHARMACY OBJECTIVES

1. To educate patients and other healthcare

professionals on the safe use of medications.
2. To ensure safe and efficient delivery of
medications in all District Health Centers in
Iloilo City.
3. To provide adequate medication supply to affected
communities during disaster occurrences.
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

4. To minimize and monitor possible medication

errors, Adverse Drug Reaction and to record
medication’s allergy status.
5. To pro-actively participate in any health awareness
program of Iloilo City Health Office.
6. To establish healthy inter-department relationship
and external organizations in promoting the quality
of medications.

Core Values
Knowledge – It is the responsibility of all staff to
share and spread knowledge information and skill to
ensure patient safety education whenever needed.
Respect - All staff must exhibit positive and
professional attitude by showing respect for
colleagues, patients and community.
Teamwork – Lends energy needed to help ordinary
people to achieve extra ordinary result.
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Innovation – Creativeness and awareness of new

current system should be adapted at all times.
Commitment - All staff shall commit to patient
satisfaction and safety with full commitment and
loyalty to our organization and community we are
serving.
Attitude - Must consistently exhibit a positive attitude.
This includes our appearance, conversation, products
and services provided.
Responsibility – Every member is fully responsible
on the job he does and always remember he is a
member of TQM (Total Quality Management).

Job Title: PHARMACIST in Public Department: Supply Chain Management

Health Division (CHO)

Section : Iloilo City District Health POS No : Permanent

Center Contract of Service (CoS)

Reporting to : Head of Supply Chain Responsible for : Patients, Physicians, Nurses

Management (CHO) & Pharmacist

Liaises with: All Pharmacy, Nursing and Medical Staff

Role of Pharmacist in Public Health

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

1. Developing disease prevention and control programs (including Medication

Safety programs) as well in health - education policies and programs.
 Advise on healthy eating and lifestyle modifications
 Prevention & management of drug , misuse & addiction
 Promoting Patient Medication Education ( Patient Medication Counseling )
 Develop programs for monitoring & reporting Adverse Drug Events
 Develop programs to intercept counterfeit medications
 Support education and training of the population at early age such as
through school health programs
 Educate health care-colleagues about safe & effective medication use
 Educate community leaders (e.g. public office holders, school officials) about and
involve them in public health initiatives.
2.Collaborating with local authorities, to address local and regional health care
needs (environmental hazards and emergency preparedness programs).
 Help in development, implementation and revision of local emergency
operation plans
 Involvement in planning for distribution, dispensing & managing drug therapy
in emergency situation
 Developing policies and initiatives to increase awareness in proper handling
and disposal of hazardous drugs
3.Providing population –based care
 By working with their health –care colleagues, pharmacist can contribute to
population specific, evidence-based diseases management programs tailored to
fit the needs of the institution and communities they serve

Duties and Responsibilities

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

 Establishes work according to District Health Center Pharmacy Policy and Procedure
Guidelines and to follow up its implementation.
 Verifies the safety of prescription for drug allergy and potential for drug-drug, drug-food,
and drug-lifestyle Interactions.
 Ensures appropriateness of medications with regards to diagnosis and contacts physicians
for verification.
 Prepares and dispenses medications to patients as prescribed by physicians and in
accordance with the pharmacy prescription policy.
 Monitors drug requisitions and supplies.
 Supervises pharmacy assistant working under him or her and ensures that medicine
reaches patient on time, dispensed correctly and perform routine patient counseling.
 Provide proper patient medication counseling.
 Performs monthly inspection for any record-keeping procedures, stock inventory and
report to pharmacy head if any discrepancy.
 Prepares quarterly report of all drugs received/RIS , dispensed, stock-on-hand with
their respective expiration dates, and any other information required.
 Updates physicians on out-of-stock medications, and recommends suitable substitutes if
required by any physician, and discusses with the Head of Pharmacy Department for
verification and clarification.
 Monitors and reports prescriptions for possible medication errors and near-misses.
 Attends pharmacy and other departmental meetings as required.
 Represents the organization in a positive and professional manner in the community.
 Maintains regulatory requirements, including Food and Drug Administration &
Department of Health.
 Follow instructions given to him/her by the head of pharmacy and reports to him as
necessary.
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

I Have read and reviewed my job description and I understand the job I am expected to
perform

Employee Name Signature Date

Approved by:

Head of Pharmacy Signature Date

Original: Employee File / HR – Personnel Section Copy: Department/ staff

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

PHARMACIST DAILY ROUTINE TASK

CHECKLIST
A.) Environmental & Infection Control

1. Switch on lights, Air condition unit and Computer.

2. Clean and wipes working surfaces, drawers, medication cabinets
and equipment with available disinfectant.
3. Records Room Temperature, Refrigerator Temperature and
Relative Humidity.
4. Prepares labels, packaging materials e.g. envelopes, and
ancillary labels for dispensing.
5. Checks adequacy of stocks.
6. Top up, replenish and arrange stocks if needed.
7. Conduct daily inventory for stocks requisition, expiry if
required.
8. Prepares forms e.g. patient receiving form, Drug Quality
Report, Drug Recall form Medication Error & Near Miss and
ADR.

B.) Dispensing of Prescription Orders

1. Check prescription for completeness & appropriateness.

2. Clarify with prescribing physicians any discrepancies in the
written orders. Document any action taken in the record
book.
3. Prepares medications and checks for accuracy against the
prescription order.
4. Review and perform double checking prior for dispensing.
5. Conduct Patient Medication Counseling.
6.
C.) Monitoring of Treatment

1. Report any Medication Error or Near Misses discovered.

2. Report any suspected Adverse Drug Reactions.
3. Report any Drug Quality Defect if any.

D.) Data Collection ( Quality Assurance)

1. Collect number of prescription dispensed.
2. Collect number of items dispensed.
3. Itemized Drug Utilization Usage
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Note: Pharmacist assigned at any district health center will submit a

monthly workload report to the head of pharmacy and medical
officers in-charged

References: Institutional Pharmacy Operation Manual 1st Edition 2023

Requirements: Institutional Pharmacies requiring license to operate
Institutional pharmacies that are required to secure an LTO are those that
meet the following criteria:
1) Non-drug establishments that regularly procure drugs to be dispensed
to their employees.
2) Drug establishments procuring drugs other than those registered to
their names to be dispensed whether at a cost or as part of employee’s
benefits and/or its dependents.

LIST OF DOCUMENTARY REQUIREMENTS FOR DRUGSTORE/

PHARMACY/ BOTICA AND SIMILAR OUTLETS LTO APPLICATIONS
A. Initial LTO Application
1) Application form
2) Proof of Business Name Registration
3) Credentials of Pharmacist and Responsible Pharmacy Assistant
(where applicable)
4) Risk Management Plan
5) Location Plan
6) Picture of Drugstore with Display of Signage
7) Proof of Payment (e.g. official receipt or authorized bank payment
slip)
8) Self-assessment Toolkit

B. Renewal LTO Application

1) Application form
2) Copy of Certification issued as a result of LTO Variation
3) Proof of Payment (e.g. official receipt or authorized bank payment
slip)
4) Self-Assessment Toolkit

C. Resistance of Lost of Destroyed LTO

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

1) Letter of Request
2) Affidavit of Loss or Destruction
3) Proof of Payment (e.g. official receipt or authorized bank payment
slip)
4) Proof of Payment (e.g. official receipt or authorized bank payment
slip)

D. Voluntary Cancellation of LTO

1) Letter of Request
2) Original LTO

E. Additional Requirements (On-Site inspection only)

1) Agreement between the franchisor and franchise, where applicable
2) Records/e-file
3) Standard Operating Procedure
4) Display of Information, Education and Communication Materials as
required
5) If with additional activity:
a. Certificate of Training of the Pharmacist
b. Documents related to the additional activity with proof of
validation
6) Reference Materials
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

RISK MANAGEMENT PLAN: HOUSEKEEPING

Description Risk Impact if Risk Responsible Timeline Preventive/
of Risk Probability Risk severity person Contingency
(High, Occurs (Critical, plan
Medium, Moderate,
Low) Low)
Contaminatio HIGH Contaminati CRITICAL Pharmacist Daily  Personnel
n of Pests in on and Pharmacist in-charge
the shelves instability of Asst. should
drug perform
product thorough
examinatio
ns
Garbage HIGH Pest CRITICAL Pharmacist Daily  Dispose
Disposal infestation Pharmacist the
Asst. garbage
when the
time for
collection
Sink (Cross- HIGH Spreading of CRITICAL Pharmacist Daily  Store
contaminatio bacteria Pharmacist water in a
n) Asst. clean
storage
with cover
and
replace
daily
Dusty MEDIUM Can lead to MODERATE Pharmacist Daily  Thorough
Shelves health Pharmacist cleaning
problems Asst. regularly
using
clean cloth
with
detergent
Slippery/Wet LOW Can lead to LOW Pharmacist Daily  Mop and
floor accidents Pharmacist dry the
Asst. floor
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Descripti Risk Impact if Risk Responsib Timelin Preventive/

on of Risk Probabili Risk severity le person e Contingency
ty (High, Occurs (Critical, plan
Medium, Moderat
Low) e, Low)
Wrong HIGH Exacerbate Critical Pharmacist Every  Pharmacist
Dispensing patients Pharmacist transactio always
illness Asst. n check the
product
before
dispensing
 Be
familiarize
about the
stocks and
knowledge
able
Wrong HIGH Misinformati Critical Pharmacist Daily  Double
Prescription on given to Pharmacist check the
Reading patient Asst. prescriptio
ns with the
pharmacist
and co-
employees
before
dispensing
SALAD MEDIUM Wrong Critical Pharmacist Daily  Always
(Sound Alike, Product Pharmacist check the
Look Alike given Asst. product
Drugs) before
given to
the patient
 Visual
verification
to the
customer
Dispensing to MEDIUM Drug abuse Moderate Pharmacist Daily  Explain
Minors Pharmacist why we do
Asst. not give
prescriptio
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

n
medicines
to
children/mi
nors
RISK MANAGEMENT PLAN: DISPENSING OF PRESCRIPTIONS DRUGS

RISK MANAGEMENT PLAN: STORAGE OF STOCKS

Description Risk Impact if Risk Responsible Timeline Preventive/
of Risk Probability Risk severity person Contingency
(High, Occurs (Critical, plan
Medium, Moderate,
Low) Low)
Rodents HIGH Contaminati CRITICAL Pharmacist Daily  Pest
infestations on of drug Pharmacist control
product Asst.

Improper HIGH Wrong CRITICAL Pharmacist Daily  Follow

stocking of dispensing Pharmacist FEFO (First
stocks Asst. expiry,
First Out)
High MEDIUM Degrade the MODERATE Pharmacist Daily  Temperatu
temperature drug Pharmacist re
reading product and Asst. mapping
unusable regularly
 Use
additional
electric fan
Stock LOW Inadequate HIGH Pharmacist Daily  Ensure the
pilferage product to Pharmacist area is
dispense Asst. locked
including
exits and
entrance
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Description Risk Impact if Risk Responsible Timeline Preventive/

of Risk Probability Risk severity person Contingency
(High, Occurs (Critical, plan
Medium, Moderate,
Low) Low)
Adverse Drug HIGH Patient CRITICAL Pharmacist Every  Patient
Reaction Death Pharmacist Transacti Counsellin
Asst. on g

Wrong HIGH Exacerbate CRITICAL Pharmacist Every  Double

Dispensing patient Pharmacist Transacti check the
illness Asst. on prescribed
drugs
before
dispensing
it to the
patient

 Correct
placement
of drugs
Spillage MEDIUM Degrades MODERATE Pharmacist Every  Check the
Manufacturin the product Pharmacist Transacti drug
g Defects Asst. on product
during
delivering

 Check
items
before
dispensing
Wrong MEDIUM Unfair price LOW Pharmacist Every  Conduct
computation discriminatio Pharmacist Transacti training to
of Senior n Asst. on all
Citizen personnel
Discount/PW on correct
D Discount computati
on of
SCD/PWD
Discount
RISK MANAGEMENT PLAN: CUSTOMER COMPLAIN ON PRODUCT
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

RISK MANAGEMENT PLAN: ENVIRONMENTAL FACTORS

RISK FACTOR ASSETS AT RISK PLAN RESPONSE
1. Fire People, property,  Install a smoke  Have safety
business operation, detector equipment
environment  Have a fire exit maintained and in
door easily found
 Buy fire locations,
extinguisher including fire
 Have a safety extinguishers and
ladder safety ladders
(and idea how to
use them). Have
all extinguishers
checked regularly
(at least once a
year) and replace
if defective.
 Practice your
escape plan
 Make sure your
smoke detectors
work
 Check appliances
regularly to
prevent fires.
2. Earthquake People, property,  Have a fire  Stay calm
business operation, extinguisher,  Follow the
environment first aid kit, a emergency plan
battery- or the instructions
powered radio, of the person in
a flashlight, and charge.
extra batteries.  Be careful around
 Learn first aid broken glass and
 Have an debris.
earthquake plan  Stay away from
at workplace shelves.
 Cover your head
when going to the
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

exit
3. Lightning and People, property,  Have an  Unplug any
Thunderstorms business operation, emergency kit electronic
environment equipment well
before the storm
arrives
 Secure any
electronic files
and save the data
4. Workplace People, property,  Install CCTV  Develop
violence business operation, cameras programs, policies
environment  Provide ample and work
lighting at practices aimed
entrances and at maintaining a
exit safe working
 Employing environment.
security staff to  Have a well-
patrol the developed plan.
premises as  Prepare
well as serve as employees
deterrents to  Practice
would-be emergency drills.
criminals  Train staff to
anticipate,
recognize and
respond to
conflict and
potential violence
in the workplace
5. Disease People, business  Require health  Provide free
operation, certificates of vitamins and
environment the staff medicines
 Have their annual
check up
 Have them
vaccinated
 Wash hands to
prevent
contamination
6. Utility outage People, property,  Have a standby  Check main fuses
business operation, generator or circuit breakers
environment to see if they
have blown or
tripped.
 Call electric
supplier
 Unplug appliances
with electronic
components
7. Lack of People, business  Have a standby  Treat each
Employee operation employee in employee like a
case of family member
emergency  Provide health
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

insurances and
other benefits
 Greet them with a
smile and
communicate
once in a while
8. Supplier Failure People, business  Have a contact  Be sure to order
operation with the the medicines and
supplier supplies before
the expected
delivery date
 Check the
availability of
medicines of the
supplier
 Check the
medicine supplies
if there is any
defective

List of References:
A. (2022, November 29). Types Of Hazardous Waste Disposal Methods

- AOTC. Alpha-Omega Training & Compliance,

Inc. https://a-otc.com/hazardous-waste-disposal-methods/

Biomedical waste management ⚡ colour coding for beginners. (n.d.).

celitron.com. https://celitron.com/en/blog/biomedical-waste-management-colour-

coding-for-beginners#:~:text=Colour%20coding%20for%20biomedical%20waste
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

%20management%3A%20yellow%2C%20red%2C,waste%205%20Pharmaceutical

%20waste%20%28discarded%2Fexpired%20medicines%20and%20drugs%29

Business Waste. (2023, January 16). Pharmaceutical Waste Disposal,

Management & Waste

Bins. https://www.businesswaste.co.uk/pharmaceutical-waste/

Center for Drug Evaluation and Research. (2018, December 20). Drug

Disposal: Dispose “Non-Flush List” Medicine in Trash. U.S. Food And Drug

Administration. https://www.fda.gov/drugs/disposal-unused-medicines-what-

you-should-know/drug-disposal-dispose-non-flush-list-medicine-trash

Choudhary, A. (n.d.). SOP for Handling & Usage of Hazardous

Chemicals.

Pharmaguideline. https://www.pharmaguideline.com/2011/06/sop-for-

handling-usage-of-hazardous.html

Department of Health Knowledge Hub.

(n.d.). https://www.knowledgehub.org.za/system/files/elibdownloads/2022-

01/SOP_Waste+Disposal+of+COVID-19+Vaccines_20122021.pdf.

Environmental, Health, and Safety Guidelines.

(n.d.). https://www.ifc.org/wps/wcm/connect/topics_ext_content/ifc_external_

corporate_site/sustainability-at-ifc/policies-standards/ehs-guidelines
 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Flood.

(n.d.). https://education.nationalgeographic.org/resource/flood/Handling sharps

and needles. (n.d.). https://medlineplus.gov/ency/patientinstructions/000444.htm

Pharmacy Assistant Job Description. (n.d.-b).

Betterteam. https://www.betterteam.com/pharmacy-assistant-job-
description#:~:text=The%20pharmacy%20assistant%E2%80%99s%20responsibilities
%20include%20creating%20and%20maintaining,to%20direct%20patients
%E2%80%99%20medication-related%20questions%20to%20the%20pharmacist.
Pharmacy and Therapeutics Committee (PTC).
https://pharma.doh.gov.ph/category/pharmaceutical-and-therapeutics-
committee-ptc/

https://www.usf.edu/research-innovation/comparative-medicine/

documents/sops/s902-procedures-handling-syringes-needles-sharps.pdf

Standard Operating Procedure (SOP) :Â Waste management of used

COVID-19 vaccines vials and ancillary supply. (2023, March 1). WHO |

Regional Office for Africa. https://www.afro.who.int/publications/standard-

operating-procedure-sop-waste-management-used-covid-19-vaccines-vials-

and

SOP Cold Chain Management. (n.d.).

Scribd. https://www.scribd.com/document/321842374/SOP-Cold-Chain-

Management#

T. (n.d.). Pharmacy Standard Operating Procedure: Disposal of Expired,

Damaged, Returned or Rejected

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Products. https://rxistsource.blogspot.com/2012/11/pharmacy-standard-

operating-procedure_3988.html

Warehouse Operations Manual

ILOILO CITY HEALTH OFFICE

Prepared by:

Mr. Reidenter D. Castillo, RPh Date:

(CoS) Pharmacist

Mr. Eliseo C. Ministros Jr. RPh Date:

(CoS) Pharmacist

Reviewed and Approved by:

 ILOILO CITY HEALTH OFFICE
2 nd
Floor, Iloilo City Hall Plaza Libertad, Iloilo City
Republic of the Philippines

Ms. Jacqueline S. Blancaflor, RPh,MSPharm Date:

Head Supply Chain Management Division (CHO)

Dr. Annabelle S. Tang, MD,MPA Date:

Acting City Health Officer