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Screenshot 2023-05-14 at 3.00.15 PM

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jNo intervention other than monitoring patient jNo permanent ‫‘□ﺑﺪون اﺛﺮ داﺋﻢ‬g…ª¦Hts H…©Hƒ—¥ƒw§¦t{p~µ□
effect
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hospitalization by at least one day.It can cause the following: jChange in -:±§g p©qsŠgƒ ]¥ ³H¯§—ƒ~H]
physiological status jNo permanent effect jsome ‘g…ª§¦th{®¦®hŠ¦Ht¦p¦H…hšv□
intervention necessary th{¶˜¦HK¶ƒw¦H‘˜r‘g…ª¦HMpwg□
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jthe patient died jpermanent disabilityjLife-threatening ‫□ﺗﺸﻮه ﺧﻠﻘﻲ‬ ‫□ﻋﺠﺰ ﻋﺎم‬ ‘g…ª¦HJ‫□وﻓﺎ‬
jA congenital malformation jHospitalization jProlonged ‫□دﺧﻮل اﻟﻤﺴﺘﺸﻔﻰ‬ ‫‘ﻟﻠﺨﻄﺮ‬g…ª¦HJph~‘g…˜v□
hospitalization and invasive intervention> ‫□اﻟﺒﻘﺎء ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ أو اﻟﺘﺪﺧﻞ اﻟﺠﺮاﺣﻲ‬

Name: ………… ………………………………………………………...………………………………………….:‫اﻻﺳﻢ‬


Profession:………………………………………………………………...…..……… ……………………………:t­fª¦H
Address:………………………………………………………………………………………………………:t§‰…ª¦Htf|¦H
.Fax…………………………………………phone…………………………..:‫………………………ﻓﺎﻛﺲ‬..………:›vpb
Sig…………………………………………date……………………….:€gQpw¦H………………………….… ……..:–h ®w¦H


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Kingdom of Saudia Arabia tgO®˜Š¦Hthr…˜¦Ht¤§ªª¦H
Ministry of Healt ‫وزارة اﻟﺼﺤﺔ‬
Management of Pharmaceutical care tUUUhU¦ƒUUUhU¦HtUUgpUU—…UUU¦HJQHOF

DRUG QUALITY REPORTDH]ƒ¦HJO®{«—…g…¡v

Product name (brand & generic) : : (‫اﺳﻢ اﻟﻤﺴﺘﺤﻀﺮ )اﻟﻌﻠﻤﻲ واﻟﺘﺠﺎري‬

Dosage form : : ±¬µƒh¦H¥¤Œ¦H

Strength & package size: : J®s˜¦H¨|~]†h¢…w¦H

Batch No : : t§hšŒw¦H¨ Q

Mfg & Exp. date : :th~¶¦HDpfw¬H€gQpv

Storage condition : : ‫ظﺮوف اﻟﺤﻔﻆ‬

Manufacturer / country of origin : : ‫اﻟﺸﺮﻛﺔ اﻟﺼﺎﻧﻌﺔ‬

Agent : :¥h¢®¦H

TYPE OF QUALITY PROBLEM ‫ﻧﻮع ﻣﻼﺣﻈﺔ اﻟﺠﻮدة‬

±©®x…{]E±nphªh¢]E±npg†hœ…hhšv
th¦p˜¦H Name:……………..………
‫اﻟﻌﺒﻮة‬ Physical ,chemical or microbiological thª¤¦H /:‫اﻟﺤﺠﻢ‬
‫اﻻﺳﻢ‬ ‫أﺧﺮى‬
Efficacy packaging …………………………….………… changes Size / volume other
Description : : ‫اﻟﻮﺻﻒ‬
Occupation:……….…………… …………………………………………………....……………….……………:thT®¦H
Adress:…………………………………………………………… ………………………………….……………:‫اﻟﻌﻨﻮان‬
Phone: ……………………………………….Fax:………… … ……………………….‫› ﻓﺎﻛﺲ‬vpf¦H
Sig:……………………………………………Date:€gQpw¦H –h ®w¦H

REPORTER DETAILS…g…¡w¦Hqvp¢Kp¬phr

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Include pharmacoeconomic literature and summarize findings (if available).

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Comparison to Formulary agents including: therapeutic advantages over drugs currently on formulary/ safety
advantages/ drugs that could be considered for deletion.

Comparative Therapy:
Generic Name Dose Cost/ Unit Usage in Total Cost
(Manufacturer) Previous
Year
#!" #
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program
Program Estimated Cost (savings): SR

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Recommendations:

Conclusions:
Include budget impact or other cost savings such as lab costs, decreased stay in hospital, labour, if applicable

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Include impact or other cost saving such as lab costs, decreased stay in hospital , labour, if applicable

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