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By S K Bohra
Define of the scope of ―Management of Medication‖ Identify the Path of Workflow Discuss the components of a ―Management of Medication‖ Discuss & establish the ―Management of Medication‖ performance criteria for Continual Quality Indicators
Well-planned & implemented Medical Management System supports Patient Safety and Improve Quality of care following ways Monitoring MOM with regards to efficiency , quality & safety Reducing practice variation , errors & misuse Reporting potential & actual medication errors Improve MOM process
Edition 2 April 2009 Serial # Edition 3 November 2011 Objective Elements 3 4 8 7 Description of standards Pharmacy services &usage of medication Hospital Formulary Storage of Medication Prescription of Medication Objective Elements 4 5 7 12 Old 8 are clubbed in 7 Observation MOM 01 MOM 02 MOM 03 MOM 04
Description of standards Pharmacy services &usage of medication Hospital Formulary Storage of Medication Prescription of Medication
MOM 06 MOM 07 MOM 08 MOM 09
Dispensing of Medication
Medication Administration Education about safe medication & food drug interactions Monitoring after Medication Administration Narcotic Drugs and Psychotropic Substances
10 2 5 /43 4
Dispensing of Medication
Medication Management Monitoring after Medication Administration Near Misses ,Medication Errors and Adverse Drug Events Narcotic Drugs and Psychotropic Substances
10 4 /48 5 4 Changes in Objective Element -b No change No change
MOM 10 MOM 11 MOM 12 MOM 13
Chemotherapeutic Agents Radioactive Drugs Implantable Prosthesis Medical Gases
4 4 3 3 61
Chemotherapeutic Agents Radioactive Drugs Implantable Prosthesis and Medical Devices Medical Supplies & Consumables
4 4 4 4 73
c) A multidisciplinary committee guides the formulation and implementation of these policies and procedures d) There is a procedure to obtain medication when Pharmacy is closed ODNM . ( MOM 1) Documented Policies & procedures guide the organization of Pharmacy services and usage of medication (There are 4 Objective Elements ) a) There is a documented policy and procedure for pharmacy services and medication usage b) These comply with the applicable laws and regulations.Pharmacy services and usage of medication.
Hospital Formulary ( MOM 2) There is a Hospital Formulary (There are 5 Objective Elements a) A list of medication appropriate for the patients and organization’s resources is developed. d) There is a defined process for acquisition of these medications. b) The list is developed and up dated collaboratively by the multidisciplinary committee c) The formulary is available for clinicians to refer and adhere to. e) There is a procedure to obtain medication not listed in the formulary ODNM .
and incorporating manufacturer’s recommendations c) Sound inventory control practices guide storage of the medications d) Sound-alike and look-alike medications are stored separately e) The list of emergency medications are defined and are stored in a uniform manner f) Emergency medications are available all the time g) Emergency medications are replenished in a timely manner when used ODNM .Storage of Medication( MOM 3) Documented Policies & procedures guide the Storage of Medications (There are 7Objective Elements ) a) Documented policies and procedures exist for storage of medication b) Medications are stored in a clean. safe & secure environment .
ventilation. light. and security All medication storage areas to be inspected as per hospital policy ( once in six months) to ensure medications stored properly ODNM .. moisture control. temperature. ensure proper sanitation. segregation.Storage of Medication Requirements …Policy & Procedure exits for storage of medication such as Medications are stored in the pharmacy/floor according to the manufacturer's or as per government recommendations….
Monitoring of all refrigerated items done twice in a day with record maintained. it will be notified to Engg deptt and all drugs to be removed & stored in other refrigerator All refrigerated medicine to be dispensed in ice box ODNM .Storage of Medication Temperature… Drugs required to be stored between temperature ranges of -10 to . When variation found repetitively.30 degree C be stored in freezer Drug requiring cold chain to be stored in refrigerator within temperature range of 2 to 8 degree C and rest of the drug shall be stored at room temperature between 15 to 25 degree C.
If the medication is commercially available in a lightresistant package. All refrigerated medicine to be dispensed in ice box ODNM . the medication may be stored on the shelf as is.Storage of Medication Light Sensitive Medicine… Medications that are considered light-sensitive. will be stored and dispensed in a manner as to protect them from light. as labeled by their respective manufacturers.
expiry dates and Warnings Standardize and limit the number of drugs concentrations available Concentrated Electrolytes are removed from Care Unit areas ( unless patients safety at risk) and specific precautions are defined & taken to prevent inadvertent administrations ODNM .Storage of Medication Medications and chemicals used to prepare medications are accurately labeled with contents .
Storage of Medication Protected from Loss or Theft… Floor Stock Nurse Supervisor responsible for control of floor stock & medications security within the hospital wards and patient care areas Controlled drugs ( Narcotics & Controlled. Medications are stored either in lockable medication carts or the medication room & when unattended these are to be locked. Others are admitted only when a pharmacist is present. Investigational & Cytotoxic and Hazardous Drugs) will be double locked at all times prior to use All drugs stores to be accessible only to authorized pharmacists and pharmacy technicians. ODNM .
Storage of Medication o Look like and Sound Like Medications… Medications which have the potential for confusion due to look-alike or sound-alike drug names or packaging are identified and treated with extra precautions to prevent error o o o Identify ( make list) Review the list annually and up date Take actions to prevent errors involving the interchange of these drugs ODNM .
While checking in wards if no expiry medications found (with in 3 months) it is essential that ODNM NO Expiry RETURN needs to be sent in same format . expired items must not be found in shelves/ racks of the licensed pharmacy.Storage of Medication Expiry Control of Medications… As per licensing regulation. Return of Expiry Drugs . These should be stored in locked cabinet exclusively for this purpose and must not be issued to patients Pharmacist has to issue batch wise so that HIS close to expiry list is effective Wards are required to return every month in advance ( during first week) expiry items close to three months using defined format F21/MTL(RED) .
o All medication storage areas to be inspected as per hospital policy ( once in six months) to ensure medications stocked as per Inventory Policy ODNM .Storage of Medication o o o Sound Inventory Control… Sound inventory control practices to be followed Ensure the drugs are available 24x7 in Pharmacy areas Ensure Emergency Medications ( as per defined list) a available in STOCKS all the time and reorder levels are defined and are replenished in defined time frame.
dated. named and signed.Prescription of Medication ( MOM 4) Documented Policies & procedures guide the Safe & rational Prescription of Medications (There are 12 Objective Elements ) a) Documented policies and procedures exist for prescription of medications b) These incorporate inclusion of good practices / guidelines for rational Prescription of Medications c) The organization determines the minimum requirements of a prescription d) Known drug allergies are ascertained before prescribing e) The organization determine who can write orders f) Orders are written in a uniform location in the medical records. legible. ODNM . timed. g) Medication orders are clear.
dose of administration and frequency / time of administration i) Documented Policy and procedure on verbal orders is implemented j) The organization defines a list of high risk medication k) Audit of medication orders / prescription is carried out to check for safe and rational prescription of medications l) Corrective and preventive action(s) is taken based on the analysis .Prescription of Medication ( MOM 4) h) Medication orders contain the name of the medicine . route of administration. where appropriate ODNM .
Use of HIS for reducing prescribing errors is desirable. Abbreviations for drug names are not be written. All medication orders to specify the drug name.Prescription of Medication Authority for Prescribing medication orders… Only Physicians authorized to prescribe medications orders & only those drugs listed in the Formulary except in specific instances. dated. named and . High Risk medications need to be verified by treating Consultant prior to administration. ODNM Medication orders are to be clear. All medication orders to be written on HIS /Prescription Form/Letterhead or Case Sheets labeled with Patient’s name and Registration number at uniform location History for drug allergies to be documented in red ink. legible. dosage or dosage range. the route of administration . the frequency and duration of administration.
dated . drug name. dose. UHID. timed. named and signed Verbal orders to be counter signed with in 24 hrs Define High risk medications Audit & CAPA ODNM .Prescription of Medication Ensure clinicians are trained / sensitized for rational( as per clinical needs in dose) prescription of medications Patient’s name. route & frequency of administration…name . legible . signature & registration number of prescribing doctor Drug allergies ascertained Uniform locations Authorization for prescribing orders Orders are clear .
E. each individual medication order must be written separately and each medication order must be signed . Orders calculated in either milligrams or micrograms doses shall be left in the units in which the calculation was made. All orders for units shall be clearly written in ―units‖.Prescription of Medication All orders for a drug dose less than one shall have a zero preceding the decimal amount. Write 2 mg instead of 2.g.25mg instead of . ODNM . Do not use decimal points or trailing zeros.g. Microgram amounts shall be clearly written as ―microgram‖ to clearly distinguish form milligrams (mg).0 mg. e.25 mg. If more than one physician is prescribing medications for one patient. write 0.
ODNM . whether or not it is to be supplied by the hospital pharmacy . when a patient is moved into or out of an intensive care unit. physician must cease the original order and write a new order.Prescription of Medication To change any of the medication orders. There shall be an automatic cancellation of drug orders when a patient changes service. The original order must not be obliterated. To cease a medication order physician must draw a line across the area of the chart where administration is recorded (after the last entry) and sign and date adjacent to this line. or when a patient is sent to the operating room or delivery room All the medications prescribed at the time of discharge should be included in the discharge summary.
intravenous. etc) ODNM . rate. eye. titrating orders for nursing staff (eg—as per BP level. mode of preparation of infusion . micro drip set or syringe pump. Skin creams: specify the area of skin on which application is required and the amount to be applied on a given occasion Infusions: specify as subcutaneous. epidural or intrathecal. as per HR. Do not use Latin abbreviations such as AU for both ears. peripheral vs central access. oral) and the number of drops to be given.Prescription of Medication Orders for research drugs can only be written by the physician involved in that research protocol Drops: specify which orifice (ear. AD for right ear. AS for left ear. For intravenous infusions----specify via regular drip set. duration. as per glucometer reading.
Batch number to be indicated on patent’s immunization card. Narcotics: Requires narcotic prescribing license number Emergencies: write ― STAT‖ next to the prescribed item Surgical / miscellaneous items: specify number of items needed and their size (eg: 16 gauge or small/medium/large/X large) .mg/kg/day in 3 divided doses is better written as --.mg thrice-a-day factoring in the patient’s weight. Avoid leaving that responsibility on the nurse/pharmacist.Prescription of Medication Insulins and insulin syringes : specify 40 Unit/ml or 100 Units/ml Oxygen: specify as --. Paediatrics: dose --. ODNM .litre/min via nasal cannula/venturi mask/ventilator Vaccines: patient leaflet to accompany each vaccine.
―Hold‖ means discontinue the medication. Verbal Orders Procedure to be defined ODNM . ―Stat‖ orders must be transcribed immediately and followed. ―Stat‖ orders must be transcribed immediately and followed.Prescription of Medication The Physician is to notify the nursing staff when ―Stat‖ orders are written. ―Hold‖ means discontinue the medication Emergencies: write ― STAT‖ next to the prescribed item Surgical / miscellaneous items: specify number of items needed and their size (eg: 16 gauge or small/medium/large/X large) The Physician is to notify the nursing staff when ―Stat‖ orders are written.
Dispensing of Medication( MOM 5) Documented Policies & procedures guide the Safe & rational Prescription of Medications (There are 6 Objective Elements ) a) Documented policies and procedures guide the safe dispensing of medications b) The procedure addresses medication recall c) Expiry dates are checked prior to dispensing d) There is a procedure for near expiry medications e) Labeling requirements are documented and implemented by the organization f) High-risk medication orders are verified prior to dispensing ODNM .
assembly of the product. The pharmacist will check the validity and efficacy of the prescription. ODNM . and Preparing a label which accurately reflects the instructions for use given on the prescription. such as form. labeling and information given for the patient.Dispensing of Medication( MOM 5) Dispense means the procedure which results in the receipt of a prescription • Interpreting (Correctly identifying the drug prescribed. and • Measuring and packaging of the drug or device Dispensing of medicines from pharmacy will be done by the hospital pharmacist in hospital according to a written prescription. and frequency of dosing ) an authorized prescriber’s prescription for a drug or device • Selecting and labeling of the drug or device prescribed. route. dosage. the appropriateness of the medicine for the individual patient.
Name of patient . including information on allergies. and over the counter medications. dosage form.Dispensing of Medication( MOM 5) The nurse shall strictly adhere to the following steps when dispensing a prescribed product. concurrent prescription drugs. if applicable and Directions for use. and – Determine that the prescription is not outdated ODNM . The nurse shall verify that drug is on the approved formulary of the hospital and verify that the prescription order includes at least the following information: – Date of issue . and quantity of drug prescribed . Name. strength. Route of administration. – Verify that prescription or prescription orders are signed by the physician – Check the patient profile for pertinent information.
STOP IMMEDIATELY.Dispensing of Medication( MOM 5) Selecting the appropriate drug or device Check the expiry date of the drug Recall : procedure applies when a defective drug or drug suspected for the same is found: Ward nurse Verbally informs Nursing Supervisor/ Immediate Manager Immediately. INFORM THE RESIDENT DOCTOR IMMEDIATELY. If the product has been administered . Nursing Supervisor/ Immediate Line Manager (Nursing ) Verbally Inform the Assistant Medical Superintendent immediately. Nurse to document the notes of the incident in the Nursing notes with Date and time of discovery. ODNM . and Expiry Date. Retain the remaining product/suspected product. Name of Product. Manufacturer's name and Batch No.
Assistant Medical Superintendent to submit completed Drug Recall Incident Form and Pharmacist Drug Recall Incident Form to V.Dispensing of Medication( MOM 5) Resident Doctor to inspect the product immediately and discretely assess patient for any ADRs/Side Effects and document the incident in the Case Sheet Assistant Medical Superintendant to supervise withdrawal of Drug from the department and if same batch issued to others then withdrawal of Drug from all departments. Report to be discussed between V. Pharmacist to submit completed report to AMS.P Medical Services. Punitive action/Rewards and Incentives to be given to respective staff. ODNM .P Medical Services and Member D&T Committee. Action taken by committee to be documented at back of incident form and followed up.
Medication administration is documented Documented Policies & procedures govern patient’s selfadministration of medication Documented Policies & procedures patient’s medication ODNM brought from out side the organization . Timing is verified from the order prior to administration.Medication Management (MOM 6) a) b) c) d) e) f) g) h) i) j) There are documented Policies & procedures for Medication Management (There are 10 Objective Elements ) Medication are administered by those who are permitted by law to do so Prepared Medication are labeled prior to preparation of a second drug Patient is identified prior to administration Medication is verified from the order prior to administration Dosage is verified from the order prior to administration Route is verified from the order prior to administration.
ODNM .Monitoring After Medication Administration (MOM 7) Patients are monitored after Medication Administration (There are 4 Objective Elements ) a) Documented policies and procedures guide for monitoring of patients after medication administration b) The organization defines those situations where close monitoring is required c) Monitoring is done in collaborative manner d) Medications are changed where appropriate based on the monitoring.
Near Misses . where appropriate ODNM .Medication Errors and Adverse Drug Events are reported and analyzed (There are 5 Objective Elements ) a) Documented procedure exists to capture Near Misses .Medication Errors and Adverse Drug Events (MOM 8) Near Misses .Medication Errors and Adverse Drug Events are defined c) These are reported with in a specified time frame d) They are collected and analyzed. e) Corrective and preventive action(s) is taken based on the analysis .Medication Errors and Adverse Drug Events b) Near Misses .
"near collision". a faulty process or system invariably permits or compounds the harm. injury. . a miss that was nonetheless very near.Near Misses . syndrome. infection. or damage – but had the potential to do so.Medication Errors and Adverse Drug Events (MOM 8) Near Misses A near miss is an unplanned event that did not result in injury. illness. fatality or damage. in other words. Although the label of 'human error' is commonly applied to an initiating event. ODNM behavior. Other familiar terms for these events is a "close call". whether or not it is evident or harmful to the patient. and should be the focus of improvement. Medication Errors A medical error may be defined as a preventable adverse effect of care. or other ailment. or in the case of moving objects. This might include an inaccurate or incomplete diagnosis or treatment of a disease. Only a fortunate break in the chain of events prevented an injury.
Medication Errors and Adverse Drug Events (MOM 8) Medical Error As a general acceptance. a medical error occurs when a healthcare provider chose an inappropriate method of care or the health provider chose the right solution of care but executed it incorrectly. as there are many types of medical error from minor to major.[ However. medical error definitions are subject to debate. harmful reactions to medicines (known as adverse drug reactions) are among the leading causes of death in many countries.Near Misses . Medical errors are often described as human errors in healthcare. and causality is often poorly determined Adverse Drug Events Unintended. The majority of adverse drug reactions (ADR) are preventable. ODNM .
Narcotic Drugs and Psychotropic Substances (MOM 9) Documented procedure guide for use of Narcotic Drugs and Psychotropic Substances (There are 4 Objective Elements ) Documented procedure guide for use of Narcotic Drugs and Psychotropic Substances which are in consonance with local and national regulations a) b) c) These drugs are stored in a secure manner Proper record is kept of the usage . administration and disposal of these drugs d) These drugs are handled by appropriate personnel in accordance with the documented procedure ODNM .
Chemotherapeutic Agents(MOM10 Documented policies and procedure guide for use of use of Chemotherapeutic Agents (There are 4 Objective Elements ) Documented policies and procedure guide for use of use of Chemotherapeutic Agents a) b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect Chemotherapy Chemotherapy is prepared in a proper and safe manner and administered by qualified personnel Chemotherapy drugs are disposed of in accordance with legal requirements ODNM c) d) .
handling . patients and visitors are educated on safety precautions ODNM . preparation. distribution and disposal of Radioactive drugs Staff .Radioactive Drugs(MOM 11) a) Documented policies and procedure govern usage of Radioactive drugs(There are 4 Objective Elements ) Documented policies and procedure govern usage of Radioactive drugs b) c) d) These policies and procedure are in consonance with laws and regulations The policies and procedure include the safe storage .
Implantable Prosthesis and Medical Devices (MOM 12) Documented policies and procedure guide the use of Implantable Prosthesis and Medical Devices (There are 4 Objective Elements ) Usage of Implantable Prosthesis and Medical Devices id guided by scientific criteria for each individual item & national / international recognized guidelines / approval for each specific items a) b) Documented policies and procedure govern procurement. storage/stocking. issuance & usage of Implantable Prosthesis and Medical Devices incorporating manufacturer’s recommendations ODNM .
Implantable Prosthesis and Medical Devices (MOM 12) c) Patient and his/ her family are counseled for the usage of Implantable Prosthesis and Medical Devices including precautions if any d) The batch and serial number of the Implantable Prosthesis and Medical Devices are recorded in the patient’s medical record and the master logbook ODNM .
Medical Supplies & Consumables (MOM 13) Documented policies and procedure guide the use of Medical Supplies & Consumables (There are 4 Objective Elements ) There is a defined process for acquisition of Medical Supplies & Consumables a) Medical Supplies & Consumables are used in a safe manner .& incorporating manufacturer’s recommendations d) Sound inventory control practices guide storage of medical supplies and consumables. where appropriate c) Medical Supplies & Consumables are stored in a clean. b) ODNM . safe & secure environment .
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