Revision and reorganization of a hospital pharmacy policy and procedure manual

The development of a hospital pharmacy policy and procedure manual which can provide employees with an immediate source of current and reliable operating information is discussed. Flexibility and the capability to be readily revised were key factors in the design of the manual. A table of contents, a referencing system and physical specifications for the manual were determined. Policies and procedures on format, writing style, distribution, responsibility, revisions and additions, and review were established. Sample policies and procedures are presented. The concept of a procedure specialist to coordinate all activities regarding the manual was examined. It is recommended that all staff members participate in the development and revision of policies and procedures.