Reference Material for Distribution

Informational materials that are used as reference guides and contain medication-related information must be approved by the P&T Committee.  

Reference materials 

Reference materials that are widely distributed across UCSF Health include but are not limited to any of the following: 

  • Antimicrobial dosing cards 
  • Renal dose adjustments 
  • Therapeutic interchange 
  • Intravenous to oral [enteral] route interchange 
  • Medication supply lists (automated dispensing cabinets, operating room lists) 
  • Medication refill lists
  • Look-Alike, Sound-Alike (LASA) medications

Submit reference materials for P&T Committee review

To submit a medication reference for consideration please provide: 

  • If new, provide the new document (and designate it as new) 
  • If it is a revision, provide the original document and proposed changes using track changes along with date of last revision (and current revision) 

The document should also include these components using this Reference Material for Distribution template.

  • Champion or their designee 
  • Presenting on behalf of [committee, group, service, department, etc.] 
  • Relevant background 
  • The current issue 
  • Relevant data/supporting material 
  • The requested action [vote to approve] with the exact recommendation that the committee will vote on 
  • The committees, services, departments, individuals that have reviewed and approved the recommendations thus far 

Reference Material for Distribution template can be directed to the Formulary Coordinator, [email protected]

Review & approval process 

These requests are presented during the recurring Pre-P&T Committee meeting live. If approved, the request would be placed on the P&T Committee Consent Agenda. This means that the P&T Committee members would receive the background and recommendation via email ahead of the meeting without a live presentation. During the P&T Committee meeting, committee members may ask for clarification or follow-up. If there are no questions, the P&T Committee will vote privately and you will be notified of the outcome within 10 days of the P&T Committee meeting vote.