MANAGEMENT OF MEDICATION

1. MANAGEMENT OF MEDICATION (MOM)

2. Documented Policies and Procedures • Selection • Procurement • Storage • Formulary • Prescription • Dispensing • Administration • Monitoring and use of medications • All included in Pharmacy/Medication Usage Manual

3. Selection • By pharmaco therapeutic (or Drugs and Therapeutic) Committee members • Representatives of major clinical departments - Administration - Pharmacist or Clinical Pharmacologists • Committee guides formulation and implementation of policies and procedures

4. Pharmaco therapeutic (or Drugs and Therapeutic) Committee • Objectives • Composition • Frequency of meetings-atleast once in three months • Quorum required • Minutes of meeting

5. Drug formulary • List of medications appropriate for the patients and Organization • Formulary keeping in mind National List of Essential Medicines and WHO Model List of Essential Medicines. • Department-wise formulary • Physical or Electronic form • Updated at regular intervals • Developed by Drugs and Therapeutic Committee

6. Frequency of prescription rejected because of Non-formulary drugs-should be monitored

7. Defined process for acquisition of formulary drugs • Vendor selection criteria • Vendor evaluation criteria • Indenting process • Generation of purchase order • Receipts of goods • Process for obtaining medications not listed in formulary Ex. local purchase/Hot line for immediate requirement

8. Storage of medications • Medications are stored in a clean,safe,secure and well ventilated environment • Medications are stored as per the manufacturers specifications • Vaccines should be preferably kept in vaccine refrigerator ( ice lined refrigerator) • Medications are protected from loss or theft • Audits will be done at regular intervals to detect loss or theft • sound alike and look alike drugs are stored separately • Temperature monitoring atleast once a day

9. Inventory control practices like first in first out (FIFO),ABC,VED,FSN and lead time analysis Medicines shall be stored in alphabetical or company name Methods to obtain medication when pharmacy is closed (preferably 24 hours pharmacy) Emergency medications are available all the time (adequate amount of emergency medications should be stored all the time) Emergency medications are replenished in a timely manner when used Available all the time Reorder level at definite quantity

10. Prescription • Medication orders only by a registered medical practitioner • Clinicians are sensitised on rational prescription of medication. • All orders in writing, and signed with date and time in the drug order sheet • Name of drug in block letters • Route, dose, strength and frequency of drug to be mentioned • Order in uniform location

11. Treatment order should be written daily • CT all,Continue same treatment not acceptable • Medication order should be Clear,legible,dated,timed,named and signed. • Only approved international abbreviations should • Dangerious abbreviations should not be used.

12. Minimum Elements of Prescription • Name of Patient • Unique Hospital Number • Drug name,dose,route and frequency • Name,signature and registration nr of prescibing doctor • Drug allergies in prominent manner both in OP and IP

13. Incase of combinations dose of all individual drug shall be written e.g. • Clopidogel with Aspirin 75mg+75mg or 75mg+150mg • Not necessary for combinations of vitamins and/or minerals

14. Policy on verbal orders • Verbal orders must not be allowed. • Written and read back between Doctor to Doctor are allowed. • Doctor to nurse only in case of emergencies. • List of approved drugs which can be ordered verbally • Verbal order shall be counter-signed by ordering doctor with in 24 hours

15. High risk medications • Medications Identified as requiring special handling throughout the medication use process • Medications involved in high percentage of medication error or sentinel events and that carry a high risk for abuse,error or other adverse outcomes. • Verified by the staff before dispensing Examples: - Narcotic drugs - Conc. electrolytes - Low therapeutic index window drugs

16. Prescription Audit • Appropriateness of the drug, dose, frequency, and route of administration; • Presence of therapeutic duplication; • Possibility of drug interaction and measures taken to avoid the same; • Possibility of food-drug interaction and measures taken to avoid the same; • Minimum component in prescription, uniform location and legibility • Done by Clinical Pharmacist or multidisciplinary committee. • Done atleast once in a month • Corrective or preventive action based on analysis.

17. Dispensing of medications • Medication recall: Based on letters from regulatory authorities or internal feedback (visible contaminant in IV fluid bottle) • Expiry date: Checked prior to dispensing • Near Expiry medication removed 3 months before expory date. • Labeling requirements: when medications are dispensed either as cut stripes or from bulk containers - Drug name - Strength - Frequency - Expiry date Physician samples not allowed High risk medication orders are verified prior to dispensing, given only after written order.

18. Medication administration • Mediations are administered either by a nurse or a doctor • Prepared medications are labeled prior to administration and preparation of a second drug • Patient is identified prior to administration by UHID no / IP no and name • Medication is verified from the order prior to administration using 7 Rights • Incomplete order should be verified prior to administration.

19. Giving Medications: Follow the Right Sequence: 1. Wash your Hands 2. Verify the order whether it is correct 3. Only Medications needed to treat the patient’s condition are ordered. 4. Ask the patient to state their name 5. Use TWO patient identifiers ( name and UHID Number) 6. Explain the medications you are giving 7. Stay with patient until medications taken 8. Document after administration 9. Monitor the effects of medication

20. Documentation of medication administration • Done in uniform location • Documentation should have - name of medication - dosage - route of administration - timing - name and signature of the person • High risk medication verification by atleast two staff (nurse-nurse or nurse-doctor) and documented

21. Record shall reflect actual administration ex: • - If brand Y was given in place of brand X, the documentation shall be of brand Y • - If the order was for a tab of 250mg but the administration was ½ a tab of 500mg the latter shall be documented

22. Policy on self administration of medication • Not allowed • If allowed reminder to take the medication before every dose and documentation on self administation

23. Medication brought from outside the organization • Not allowed • If allowed pre requisition - invoice - clear label with name of the drug, dose, expiry date

24. Education of patients and family members abt safe medication and food-drug Interactions • List of drugs: Digoxin Warfarin • Diet during medication ex: no alcohol when taking metronidazole

25. Monitoring after medication administration • Patients are monitored after medication administration and this is documented • Close monitoring is required for conc. Electrolyte,high risk medication and chemo drugs • Monitoring is done in a collaborative manner by nurse,doctor and pharmacist • Medications are changed where appropriate based on monitoring. • Defination of adverse drug event: any untoward medical occurrence that may present during treatment with a medicine but which does not necessarily have a causal relationship with this treatment • Adverse drug events are collected and analyzed by Drugs and Therapeutic committee

26. SEVERITY SCALE OF ADR’S • All ADR’s with severity level of 5 and 6 are investigated in detail by doing a Root Cause Analysis (RCA) • Level 1 – ADR Occurred but required no change in treatment with suspected drug. • Level 2 – Drug hold, discontinued or changed but no antidote or additional treatment needed • Level 3 – Drug hold, discontinued or changed and/or antidotes or additional treatment

27. Level 4 – ADR Required patient transfer to an intensive Care setting • Level 5 – ADR Caused permanent harm to the patient • Level 6 – ADR Either directly or indirectly led to the patients death.

28. Stop the drug • Inform the concerned doctor • Inform the Medical Superintendent’s Office • Fill up the Incident form • Data will be collected on a monthly basis and presented at the Quality Steering Committee

29. Narcotic drugs and psychotropic substances • Always kept in double lock • Issued from pharmacy only with a manual Prescription • Specimen Copy of Dr’s Signature to be available • Unused portion to be discarded in the sink in front of 2 witnesses and the same to be documented Return the empty vial to Pharmacy

30. Chemotherapeutic agents • Prescribed by the medical oncologist or a competent trained person • Prepared and administered by qualified personnel • Preparation done under laminar airflow. • Done by staff who have received special training • Disposed as per waste management rules

31. Disposal of chemotherapy drugs • Chemotherapy drugs are disposed off in accordance with bio-medical waste management and handling rules 1998 or manufacturers recommendations

32. Near Miss,adverse drug event and medication errors • Definition • Time frame for reporting • All these are collected and analysed by multidisciplinary committee • Analysis done in a defined time frame. • Corrective and/or preventive action where appropriate

33. Medication Errors • Prescription Error • Transcription Error • Dispensing Error • Administration Error

34. Radioactive drugs • Storage, preparation, handling, distribution and disposal according to AERB guidelines • Staff, patients and visitors are educated on safety precautions

35. Implantable prosthesis • Criteria for selection of implantable prosthesis: Based on scientific criteria national internationally recognized approvals • Relevant and sufficient data are available before selection • The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook.

36. Medical gases • Policies and procedures for - procurement - handling - storage - distribution - usage - replenishment • Uniform color coding system • Appropriate safety measures • Appropriate t\records are maintained

37. Crash Cart • Sealed crash cart in areas and seal checked daily by nurses and documented • Uniform list of drugs across the organisation • Crash cart is checked once in a month and when ever it is opened by pharmacy • Medication replaced with in 1 hour

38. THANK YOU