MMS Project 2022

Assessment of all departments and the corrective action plan:

1- Assessing the base knowledge of drug calculation program: done through almost 75% of units which
reflected into the attached matrix excel sheet

2- Assessment of departmental needs of staff regarding the MMU orientation program into the
attached file

3- Assessing the most commonly used cardiovascular medications + orientation

4- Assessing the most common problems during the medication process: meeting done with all head
nurses regarding how to facilitate the medication process
5- Assessing the controlled drugs pathway within the involved departments
6- Assessment and auditing the dispensing process of medication from the pharmacy as agreed with
Mr. Ibrahim Khedr

Department Time of sending the drug Time of dispensing the

sheets medications
GW “Post Cases” 10:30 14:30
PICU & AICU 14:30 16:00
CCU 16:00 17:00
New GW “Pre-Cases” 17:00 18:00

7- Choosing MMU link nurses within all departments and making a group to be updated with any
notes or updates regarding the medication process
8- Developing a MMU Audit Form for making close observation of the running medication process
involving all the MMU link nurses within it

https://docs.google.com/forms/d/1OCMNZBJTN485S9eUwMKNFsAgTYuQMPQXARYCVyZYsP8/
edit?usp=drivesdk
9- Orientation process includes the following:

1. Routes of Administration
 MMS Project 2022

2. Drug Calculation
3. Medication Preparation
4. Common Drug Errors
5. Commonly Used Drugs
6. Drug Interactions/ Compatibility
7. Controlled Drug Policy
8. Double Checking Medication
9. Syringe Drivers
10. Infusion Drivers
11. Labeling Codes
12. Double Checking Medication
13. Changing Inotropes
14. Intravenous Infusions
15. Refrigerated Drugs
16. High Alert Drugs
17. LASA
18. Highly concentrated Drugs

10- Until this assessment we have the following problems for our follow up and correction:
 Infection control measures within medication administration
 Double check problems
 Infusion rate calculation at ICU
 Inotropic dosage at GW, CCU and OPD
 Labelling errors
 Pediatric emergency doses guidelines
 Narcotic management especially at AICU and PICU “Must be separated”, and OPD “Chloral
management and dispensing “
 Medication rooms are not closed after being used
 No enough syringe and infusion drivers at GW and CCU
 Delayed preparation and dispensing of medications by the pharmacy
 Bad quality of labelling papers “too loose”
 Changing the inotropic concentration must be highlighted and checked by the nurse in
charge
 TPN is being administered at GW  Must be administered at ICUs
 No list for the expired or nearly expired medications  ongoing correction is being collected
11- After the initial assessment we would like to thank you for your commitment and strict adherence to
the improvement plan

Prepared by Mr. Mohammed Ibrahim 90