Department of Pharmacy

Unit Medication Floor Stock Request Form

Requests to modify the unit floor stock may only be initiated by the area nurse manager.  The request must be submitted on-line using the form below.  Requests for changes are presented to the Medication Use Process (MUP) Committee.  The committee will review requests in accordance with Deparment of Pharmacy Policy and Procedure 08.07, "Floor Stock."
Medication Name
Strength
Dosage Form Injection      Oral      Rectal       Topical
Request Type Add            Delete
Indication  
Non-emergent            Emergent
Expected Frequency of Use Daily     Weekly    Monthly
Nursing Station
Nurse Manager
Requestor
Insert further justification in the space below.

Extension:             Pager:     

The medication meets the following criteria for inclusion into floor stock:  (Check all that apply)

The medication a controlled substance.
The medication is on the approved stat list (Dept. of Pharmacy Policy and Procedure 07:61)
The unit is an intensive care unit
The medication is a safety or a reversal agent.
The medication is used frequently, and is low risk in regards to adverse drug event.
The patient care unit is a clinic where a licensed practitioner with appropriate clinical privileges controls prescription ordering, preparation, and administration.

Recommendations from the MUP committee must be reviewed by the Pharmacy and Therapeutics Committee.  You will be notified of the committee's decision to accept or reject your request within 6 weeks.