MANAGEMENT OF MEDICATION

Chapter IV

G ROUP M EMBERS

11040141019 11040141020

Bhagyashree Damle Rakesh Jondhale

11040141022
11040141023 11040141024

Priyanka Wankhede
Abhishek Gupta Vinodkumar Meena

National Accreditation Board for Hospitals & Healthcare Providers

C HAPTER 4.

MANAGEMENT OF MEDICATION (MOM)

MOM.1

P OLICIES AND PROCEDURES GUIDE THE

ORGANIZATION OF PHARMACY SERVICES AND USAGE OF MEDICATION
Objective elements

There is a documented policy and procedure for pharmacy services and medication usage. These comply with the applicable laws and regulations. A multidisciplinary committee guides the formulation and implementation of these policies and procedures

National Accreditation Board for Hospitals & Healthcare Providers

MOM.2
T HERE IS A HOSPITAL FORMULARY
Objective elements

A list of medication appropriate for the patients and organizations resources is developed The list is developed collaboratively by the multidisciplinary committee There is a defined process for acquisition of these medications

There is a process to obtain medications not listed in the formulary

National Accreditation Board for Hospitals & Healthcare Providers

MOM.3

P OLICIES AND PROCEDURES EXIST FOR

STORAGE OF MEDICATION
Objective elements

Documented policies and procedures exist for storage of medication

Medications are stored in a clean, well lit and ventilated environment

Sound inventory control practices guide storage of the medications

National Accreditation Board for Hospitals & Healthcare Providers

Medications are protected from loss or theft Sound alike and look alike medications are stored separately There is a method to obtain medication when the pharmacy is closed Emergency medications are available all the time Emergency medications are replenished in a timely manner when used

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MOM.4

P OLICIES AND PROCEDURES GUIDE THE

PRESCRIPTION OF MEDICATIONS
Objective elements

Documented policies and procedures exist for prescription of medications

The organization determines who can write orders

Orders are written in a uniform location in the medical records

National Accreditation Board for Hospitals & Healthcare Providers

Medication orders are clear, legible, dated, named and signed Policy on verbal orders is documented and implemented The organization defines a list of high risk medication

High risk medication orders are verified prior to dispensing

National Accreditation Board for Hospitals & Healthcare Providers

MOM.4 P OLICIES AND PROCEDURES GUIDE THE SAFE

DISPENSING OF MEDICATIONS
Objective elements

Documented policies and procedures guide the safe dispensing of medications The policies include a procedure for medication recall Expiry dates are checked prior to dispensing Labeling requirements are documented implemented by the organization and

National Accreditation Board for Hospitals & Healthcare Providers

MOM.5 & 6

T HERE ARE DEFINED PROCEDURES FOR

MEDICATION ADMINISTRATION
Objective elements

Medications 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

National Accreditation Board for Hospitals & Healthcare Providers

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

Timing is verified from the order prior to administration

National Accreditation Board for Hospitals & Healthcare Providers

Medication administration is documented Polices and procedures govern patients self administration of medications Polices and procedures govern patients medications brought from outside the organization

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MOM.7

P ATIENTS AND FAMILY MEMBERS ARE

EDUCATED ABOUT SAFE MEDICATION AND FOOD - DRUG INTERACTIONS
Objective elements

Patient and family are educated about safe and effective use of medication Patient and family are educated about food-drug interactions

National Accreditation Board for Hospitals & Healthcare Providers

MOM.8

P ATIENTS ARE MONITORED AFTER

MEDICATION ADMINISTRATION
Objective elements

Patients are monitored after administration and this is documented Adverse drug events are defined

medication

Adverse drug events are reported within a specified time frame

National Accreditation Board for Hospitals & Healthcare Providers

Adverse drug events are collected and analysed Policies are modified to reduce adverse drug events when unacceptable trends occur

National Accreditation Board for Hospitals & Healthcare Providers

MOM.9

P OLICIES AND PROCEDURES GUIDE THE

USE OF NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES

Objective elements Documented policies and procedures guide the use of narcotic drugs and psychotropic substances These policies are in consonance with local and national regulations

National Accreditation Board for Hospitals & Healthcare Providers

A proper record is kept of the usage, administration and disposal of these drugs These drugs are handled by appropriate personnel in accordance with policies

National Accreditation Board for Hospitals & Healthcare Providers

MOM.10

P OLICIES AND PROCEDURES GUIDE THE

USAGE OF CHEMOTHERAPEUTIC AGENTS

Objective elements Documented policies and procedures guide the usage of chemotherapeutic agents Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

This shall preferably be a medical oncologist or a person who has been trained and has achieved competency in the same.

National Accreditation Board for Hospitals & Healthcare Providers

c)

Chemotherapy is prepared and administered by qualified personnel This shall preferably be staff who have received special training in preparing and administration Chemotherapy drugs are disposed off in accordance with legal requirements These shall be disposed off according to BMW management and handling rules 1998 or manufacturer's recommendation.

c)

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National Accreditation Board for Hospitals & Healthcare Providers

MOM.11 P OLICIES AND PROCEDURES GOVERN USAGE

OF RADIOACTIVE OR INVESTIGATIONAL DRUGS

Objective elements. Documented policies and procedures govern usage of radioactive or investigational drugs These policies and procedures are in consonance with laws and regulations This Interpretation refers to o AERB guidelines.

National Accreditation Board for Hospitals & Healthcare Providers

The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs Staff, patients and visitors are educated on safety precautions It should be demonstrated in practice. Appropriate signage should be used at all the places.

National Accreditation Board for Hospitals & Healthcare Providers

MOM.12 P OLICIES AND PROCEDURES GUIDE THE USE

OF IMPLANTABLE PROSTHESIS

Objective elements. Documented policies and procedures govern procurement and usage of implantable prosthesis Selection of implantable prosthesis is based on scientific criteria and internationally recognized approvals The organization shall ensure that relevant & sufficient scientific data are available before selection. It shall also look for international or national notification for approval of the particular product. The batch and serial number of the implantable prosthesis are recorded in the patients medical record and the master logbook

National Accreditation Board for Hospitals & Healthcare Providers

MOM.13 P OLICIES AND PROCEDURES GUIDE THE

USE OF MEDICAL GASES

Objective elements Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. The policies and procedures address the safety issues at all levels

National Accreditation Board for Hospitals & Healthcare Providers

Appropriate records are maintained in accordance with the policies, procedures and legal requirements.

National Accreditation Board for Hospitals & Healthcare Providers

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