Medication Management & Use

Presented By:
Dr.Ankita Sood Sharma
Clinical Auditor ,Clinical Governance

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STANDARD 1.Medication use in the hospital is organized to meet patient needs, complies with applicable laws and regulations,
and is under the direction and supervision of a licensed pharmacist or other qualified professional
 Written Document that has component (MMU Plan- Reviewed annually )-Consisting of

 Planning

 Selection and procurement

 Storage

 Ordering

 Preparing and dispensing

 Administration

 Monitoring

 Medication error and adverse event reporting

 Evaluation

 Uniform Medication Dispensing & Distribution system

 Process for distributing medication from pharmacy to ward & other patient care areas to reduce errors , thus ensuring that correct medication is delivered to the correct
area for the correct patient .

Refer to Policy : MMU-026 (Dispensing and Delivery: Medications)

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STANDARD1.1: Thehospitaldevelopsandimplementsaprogramfortheprudentuseofantibioticsbasedontheprincipleofantibioticstewardship

1. Antibiotic Stewardship Program

 involves infection prevention and control professionals, physicians, nurses, pharmacists, trainees, patients, families, and others.

 based on scientific evidence, accepted practice guidelines, and local laws and regulations.

 guidelines for the optimal use of antibiotic therapy for treatment of infections, including the proper use of prophylactic antibiotic therapy

 tracking patterns of antibiotic prescribing and resistance, informing staff on antibiotic use and resistance on a regular basis, and educating staff about optimal
antibiotic use.

 Effectiveness of the antibiotic stewardship program is monitored which is overseen by Antibiotic stewardship Taskforce and appropriate actions are taken to
ensure the compliance
STANDARD 2: There is a method for overseeing the hospital’s medication list, including how listed medications are used; a method for
ensuring medications for prescribing or ordering are stocked; and a process for medications not stocked or not normally available to the
hospital or for times when the pharmacy is closed
 List of medications (Formulary) by both brand name and generic name, stocked in the hospital or readily available from outside sources, and the
list is reviewed annually

 Process to develop the list (unless determined by regulation or an authority outside the hospital) includes representation from all those who
prescribe and manage medications in the hospital

 Pharmacy & Therauptic committee maintain & monitor the medication usage in hospital

 Decision to add or remove medications is guided by criteria that incudes indication for use , effectiveness , risk & costs.

 Process for obtaining medications during the night or when the pharmacy is closed and for obtaining medications not stocked or not normally
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STANDARD 3 : Medications are properly and safely stored

 Medications are stored under conditions suitable for product stability as per manufacturers guidelines including medications stored on individual patient
care units & ambulances

 Controlled substances are accurately accounted as per applicable laws & regulations

Count check prior and after every shift – signature required

Logbook

Key with Team Leader / assigned Staff Member at all times.

 Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings.

 Management of medications or products that require special handling such as such as hazardous medications, radioactive medications, and investigational
medications – a risk assessment to be performed

 All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly

 Inspection done by Pharmacy Department on monthly

 Protected from theft and loss

REF: Policy : MMU 005 - Medication Storage & Inspection

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STANDARD 3.1 : Emergency medications are available, uniformly stored, monitored, and secure when stored out of the pharmacy. 𝖯

 Available in the units when they will be needed and readily accessible in AHD to meet emergency needs.

 Process on how emergency medications are uniformly stored; maintained; replaced when used, damaged, or out of date; and protected from loss or theft.

 Storage of Emergency medication in crash carts to be same across hospital –Adult as well as Peads

 Tracking break-away locks – where stored , number & log

 Storage areas as well as emergency boxes shall be accessible only to designated and authorized personnel and is secured all the time

 The security tag with a unique identifier will be used for areas in the Anesthesia rooms, or crash carts.

 Emergency medications are monitored and replaced in a timely

STANDARD 3.2 :The hospital has a medication recall system

 a process for receiving and acting on notifications of medication recalls which includes identifying, retrieving, and returning, or safely and properly
destroying, medications recalled by the manufacturer, supplier, or regulatory agency.

 process for use of unopened, expired medications and outdated medications.

 a process for the destruction of medications known to be expired or outdated.

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STANDARD 4:The hospital identifies and documents a current list of medications taken by the patient at home and reviews the list against all
new medications prescribed or dispensed.
 iidentification of the information that need to reconcile current and newly ordered medications.
 Patient’s medical records contain a list of current medications taken prior to admission or registration as an outpatient, and this information is made available to the
patient’s health care practitioners and the pharmacy as needed
 Process - Initial medication orders are compared to the list of medications taken prior to admission.

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STANDARD 4.1 : The hospital identifies those qualified individuals permitted to prescribe or to order medications

 Only privileged Medical Staff may prescribe pharmaceuticals for both inpatients and outpatients.

 Process to place limits.

 Maximum doses for medications will be utilized to ensure proper use.

 Individuals permitted to prescribe medications are known to those who dispense the medications.

STANDARD 4.2 : The hospital identifies safe prescribing, ordering, and transcribing practices and defines the elements of a
complete order or prescription
 Prescribing, ordering, & transcribing are guided by policies and procedures

 Safe.

 Implements a process related to illegible prescriptions and orders, including measures to prevent continued occurrence.

 Training of Staff.

 Patient records contain a list of current medications taken prior to admission or registration as an outpatient.

 Information is made available to the pharmacy and the patient’s care providers.

 Initial medication orders are compared to the list of medications taken prior to admission

 Defines the elements of a complete order or prescription

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 STANDARD 4.2 : The hospital identifies safe prescribing, ordering, and transcribing practices and defines the elements of a
complete order or prescription

 Patient identification.
 Essential elements.
 Generic name versus brand name.
 Whether or when indications for use are required on medication orders, including PRN.
 The types of orders that are weight based or otherwise adjusted, such as for children, frail elderly, and other similar
populations.
 Rates of administration when intravenous infusions are ordered.
 Other special orders such as titrating, tapering, or range orders.
 Actions to be taken for incomplete orders, illegible or unclear.
 Precautions for ordering medications with look-alike or sound-alike names.
 Other additional types of orders:
 Emergency
 Standing
 Automatic stop
 Verbal versus telephonic medication orders and the process to verify such orders.
 Read back policy
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STANDARD 4.2 : The hospital identifies safe prescribing, ordering, and transcribing practices and defines the elements of a complete
order or prescription
 Elements of a complete order

 Patient name

 Date and Time

 Drug name (Generic name as much as possible)

 Exact dosage (expressed in metric system)

 Dosage form

 Route of administration

 p.o. is understood unless otherwise indicated

 Exact schedule/frequency of administration

 The notation "PRN" if the order is PRN

 Indication for use for PRN orders, where applicable

 Duration of order where indicated

 Miscellaneous information as required (directions/considerations)

 Signature of person taking verbal/telephone order

 Signature
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American practitioner
Hospital Dubai
STANDARD 5 :Medications are prepared and dispensed in a safe and clean environment.
 Medications are prepared and dispensed in clean, uncluttered, safe, and functionally separate areas with appropriate medical equipment and supplies

 Staff preparing/compounding sterile products/medications are trained and competent in the principles of medication preparation and aseptic techniques and are
provided resources to support the medication preparation process

 Guidelines for use of single-use and multidose vials are identified and implemented in the medication processes

 Medications stored, prepared, and dispensed from areas outside the pharmacy (for example, patient care wards) comply with the same cleanliness measures
required in the pharmacy.

Refer: MMU-028,Processing & Preparation of Intravenous Amixture, Unit Dose compounding & Multidose Medication

STANDARD 5.1 :Medication prescriptions or orders are reviewed for appropriateness

 Includes evaluation of:

 Appropriateness of the drug, dose, frequency, and route of administration.

 Therapeutic duplication.

 Real or potential allergies or sensitivities.

 Real or potential interactions between the medication and other medication or food.

 Variation from organization criteria for use.

 Patient’s weight and other physiological information.

 Other contraindications

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STANDARD 5.1 :Medication prescriptions or orders are reviewed for appropriateness
 Critical elements of an appropriateness review:

 Allergies

 Lethal drug/drug interactions

 Weight-based dosaging

 Potential organ toxicity (for example, administration of potassium sparing diuretics in patients with renal failure)

 Reviewed prior to dispensing.

 There is a process to contact the individual who prescribed the medication when questions arise.

 Review of orders are done by qualified Staff.

 Review is facilitated by a record for all patients receiving medication.

 Computer software when used is periodically updated.

STANDARD 5.2 :A system is used to safely dispense medications in the right dose to the right patient at the right time.

 Uniform medication dispensing and distribution.

 Dispensed in the most ready to administer form.

 The system supports accurate and timely dispensing and documentation of dispensing practices.

 After preparation, medications not immediately administered are labeled with the name of the medication, the dosage/concentration, the date prepared, the
expiration date, and two patient identifiers

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 STANDARD 6 :Qualified individuals permitted to administer medications are identified and document the medications that are administered
in the patient’s medical record
 Identified by job description or the privileging process, authorized to administer medications.

 Only those permitted by AHD and by relevant licensure, laws and regulations administer medications.

 Process to place limits, when appropriate, on the medication administration of individuals

 Medication administration is recorded for each dose.

STANDARD 6.1 :Medication administration includes a process to verify the medication is correct based on the medication prescription or
order
 Medications are verified with the prescription or order.

 The dosage amount of the medication is verified with the prescription or order.

 The route of administration is verified with the prescription or order.

 Patients are informed about the medications that they are going to be given and have an opportunity to ask questions.

 Medications are administered on a timely basis

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 STANDARD 6.2 : Policies and procedures govern medications brought into the hospital by the patient or family and medication prescribed
for patient self-administration
 Self (patient) administration of medications:
 Requires Physician order.
 Instruction to patient/family – documented.
 Always kept in the original container and labeled.
 Patient’s own medications:
 Physician order required – itemized.
 Sent to Pharmacy to be checked.
 Patient/family education

STANDARD
All Vendor and 6.2.1
Company:Policies and procedures
requests govern medications
regarding appointments, brought
presentations and into the hospital
introducing of newassamples
samplesgo through the Pharmacy Department.
The Director of Pharmacy will liaise with the Physicians regarding these requests.
 Only registered (United Arab Emirates) medications will be accepted for sample medications and only in exceptional circumstances and no
medication part of a trial, observational study, promotional study or marketing shall be accepted.
 Medications not part of the AHD formulary shall not be accepted unless as part of a patient’s continued care treatment plan which may have been
initiated in another setting or country.
 The Pharmacy will keep a record of all sample medications available for patient use.
 All sample medications will be prescribed, dispensed and control as per the requirement of medication orders.
 The Pharmacy Services will keep a record of sample medications dispensed to patients and assure proper documentation in the patient’s medical
record.
 Care areas other than the Pharmacy can store sample medication only if:
 The medication had been approved as sample medication, logged in the Pharmacy and dispensed to the care area as ward stock by the Pharmacy.
 The Drug Sample Receiving Log and Drug sample Dispensing Log Forms are completed by the Physicians and copies forwarded to the Pharmacy
after each entry.
 Samples must be stored in a separate container in the designed medication storage area and must be locked/secured and accessed only by
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authorized staff members.
STANDARD 6.2 .1 : Policies and procedures govern medications brought into the hospital as samples
 Date of order and dispensing of sample medications must be recorded in the patient’s medical record.
 The patient’s response to the medication must be recorded in the patient’s medical record including any side effects or Adverse Drug Reaction (ADR).
 ADR’s should be reported on the electronic reporting system (Safe Point).
 All Physicians prescribing sample medication must submit a quarterly report to the P&T Committee detailing the following:
 Medical Record Numbers of patients receiving the sample medications.
 Monitoring of the effect of the medication.
 Number of medications ordered and dispensed.
 Requests for additions of sample medications to the AHD Formulary shall not be reviewed.
 Physicians will not dispense and distribute samples without the knowledge and involvement of the Pharmacy Service and without monitoring of the effect and
outcome of these samples.
 Physicians will not accept samples from Pharmaceutical Vendors without having completed the appropriate requests and log book .

STANDARD 7 :Medication effects on patients are monitored

 Medication effects on patients are monitored.
 Medication adverse effects on patients are monitored and documented.
 The hospital has a process for recording in the patient medical record, adverse effects related to medication use and reporting adverse effects to the hospital.
 Adverse effects are documented in the patient’s medical record as identified.
 Adverse effects are reported as identified by the process in the time frame required.

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 STANDARD 7.1 :The hospital establishes and implements a process for reporting and acting on medication errors and near misses (or close
calls).
 Medication error and near miss are defined.

 Reported using an established process.

 Inform MRP immediately and monitor the patient

 Report in Safe Point .

 To Manager within 24 hours

 To Director of Pharmacy within 72 hours.

 Those accountable for taking action on the reports are identified.

 Uses medication errors and near misses reporting information to improve medication use process.

 To PI for central record keeping.

 Discussed in P&T.

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 Presentation
title here
November 2019

Thank you.

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