Parenteral Monograph and Pump Library Change Request

Complete this form to request the creation of a new parenteral drug monograph or updates to an existing monograph in the Manitoba Acute Care Formulary, including any updates to infusion pump libraries.

Please clearly summarize the proposed changes, provide clinical justification, and cite or attach any relevant supporting literature where available.

If the request is associated with a patient safety incident or identified safety risk, this should be indicated and described.

Note: Incomplete forms or missing documentation may delay review.

Parenteral Monograph and Pump Library Change Request

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Date Requested:*

YYYY dash MM dash DD

YYYY-MM-DD

Site:*

REQUESTED DRUG

Please indicate the status of the parenteral monograph or pump library change:*

No current monograph

Current monograph requiring updating/changes

IV pump library requiring update

Drug Name:*

IV Pump Type (if known):

Section Requiring a Change

Which monograph section(s) does this request apply to?

Special Considerations

Administration Policy & Monitoring

Parenteral Dosage Forms

Compatibility & Stability

Reconstitution

Adult Administration

Pediatric Administration

All Dosage Forms

Other

If Other, please specify:*

CLINICAL JUSTIFICATION AND CRITERIA FOR CHANGE

Summarize the changes proposed (include reasoning for why the monograph draft/changes should be made):*

Cite and/or attach published supporting literature, if available (i.e. peer-reviewed controlled studies, clinical guidelines, common drug review, product monograph, etc.):

Attach published supporting literature, if available (i.e. peer-reviewed controlled studies, clinical guidelines, common drug review, product monograph, etc.):

Drop files here or

Max. file size: 5 MB, Max. files: 4.

Did the information, or missing information, on the existing parenteral drug monograph contribute to a patient safety incident?*

Yes

If Yes, please explain:*

REQUESTER INFORMATION

Name:*

First Last

E-mail address:*

Title / Role:*

Department:*

This site is not intended to be used by the general public. If you are not a health care professional or a Shared Health staff member, please refer to our public website.

This website is supported by Digital Shared Services