Medication Management and Use Plan Template (JCI Requirement)

1.      PURPOSE:

1.1.      To establish a process for medications, use in the organization that complies with applicable laws, regulations and organized to meet patient needs.

1.2.      To ensure efficient and effective medication management system and use throughout the organization.

 

2.      APPLICABILITY:

2.1.      Pharmaceutical Services department.

2.2.      Pharmaceutical and therapeutic team.

2.3.      Nursing department.

2.4.      Medical Departments

2.5.      Logistics department.

2.6.      All departments in which pharmaceutical products are stored.

 

3.      POLICY:

3.1.1.   As per (Organization Name) Medication Management and Use plan, all information and experience related to the hospital system shall be utilized in the hospital systems review annually. This will allow (Organization Name) to understand the need and priority of continued system improvements in quality and safety of medication usage.

3.1.2.   The effective medication management program shall include all parts of the hospital’s inpatient and outpatient.

3.1.3.   All settings, services and individuals that manage the medication process are included in the organizational structure.

3.1.4.   The Medication Management and Use Plan will be reviewed annually to ensure efficient and effective medication management and use, the review includes the elements of Medication Management Program.

3.1.5.   Selection and procurement of the medication.

3.1.6.   Storage (including Hazard Drug storage)

3.1.7.   Ordering and transcribing

3.1.8.   Preparing and dispensing

3.1.9.   Administration and monitoring

3.1.9.1.1.The Continuous Quality Improvement Department of the hospital shall receive regular reports of the activities of the medication management from the Pharmacy and Therapeutics Committee.

3.1.9.1.2.   The Continuous Quality Improvement Department shall review the reports and as appropriate, communicate concern about identified issues back to the chairman of pharmaceutical care services and to the clinical staff.

3.1.9.1.3.The Pharmacy and Therapeutics committee oversees the medication management system in the hospital, develops and approves the policies and procedures, coordinates the required training program, and initiate the quality improvement projects.

3.1.9.1.4.The Director of Pharmaceutical care Services Department shall also collaborate with the Chairman of the Pharmacy and Therapeutic Committee develop reports of medication management program, these will be presented to the Pharmacy and Therapeutics committee meeting including any change in the drug formulary, performance management and improvement activities, and any other medication issues.

3.1.9.1.5.Licensed pharmacy staff are responsible for implementing the appropriate organizational, departmental, and job descriptions required to achieve the highest level of medication management and minimize the potential of diverse outcomes of care and patient safety.

3.1.9.1.6.Pharmacy and Therapeutics committee has recommended and standard precautions or universal precautions be taken in handling hazardous drugs. Given the addition of many non –antineoplastic drugs, drugs in tablet and/or capsule form to the list, no single approach can cover the diverse potential occupational exposures to the drugs. The current NIOSH approach involves three groups drugs:

3.1.9.1.7.Group 1: Antineoplastic drugs (AHFS Classification 10:00) (ASHP/AHFS DI 2013). Note that many of  these drugs may also pose a reproductive rick for susceptible populations.

3.1.9.1.8.Group 2: Non-antineoplastic drugs that meet one or more of the NIOSH criteria for a   hazardous Drug. Note that some of these drugs may also pose a reproductive risk for susceptible populations.

3.1.9.1.9.Group 3: Drugs that primarily pose a reproductive risk to men and women who are actively trying To conceive and women who are pregnant or breast feeding, because some of these drugs may be present In breast milk .

 

4.      PROCEDURE:

4.1 Elements of Medication Management and Use Program Plan

4.1.1 Planning / Procurement:       

A.    Hospital develops the medication list of all medication stocked normally in the hospital (drug formulary list).

B.     The Pharmacy and Therapeutics committee maintain and monitor the medication list and to monitor the use of medication in the hospital and any new medication added to the formulary for 6 months.

3. Drug formulary list is listed alphabetically and includes complete drug monograph.
4. The list reviewed annually based on emerging safety and efficacy information, medication error and adverse drug events.
5. Drug formulary list is distributed to all medical staff and nursing units through hospital information System.
6. Physicians makes request for adding or deleting medications from the drug formulary list, then Reviewed and evaluated by Clinical Pharmacist , then approved by Pharmacy and Therapeutics Committee.

4.1.2        Drug Shortages:

1. Medical supply arranges the drug from other sources when not available in the hospital: such as local drug agents, or other hospitals.
2. Pharmacy provides notification information to all concerned for long term shortage.
3. Pharmacist selects available drug as alternative, with its generic equivalent drug, when the prescribed drugs is out of stock and then advises the prescriber on the substitution.
4. Emergency medication not available in the pharmacy is brought to the patient within 24 hours through proper communication with other hospitals.

4.1.3 Storage:

1. The medications are stored in the hospitals in the following areas:
2. A1) Pharmacy
3. A2) Hospital Wards
4. Medication is stored under conditions suitable for product stability.
5. Temperature for all mediations and IV solutions storage areas are monitored and ensure the stability within the normal range by air condition refrigerator.
6. Pharmacy observes all check list for temperature of medication storage areas, also sign and write frequency.
7. Narcotic and controlled medications are stored in special cabinets that have double lock and accurately accounted according to the Ministry of health and Saudi Food Drug Authority laws and regulations.
8. Medications and chemicals used to prepare mediations (extemporaneous preparations) are labelled with open date, the contents, expiry date and special warnings.
9. The (Organization Name) has a safe and secure system for the storage and safe management of hazardous medications and pharmaceutical chemicals ((Organization Name) System for Hazardous Medications).
10. Concentrated electrolytes are stored in a separated cabinet and also locked and labelled with blue label in critical areas (e.g. ICU, ER & OR).
11. Emergency medications are stocked in the wards in safe and secured places with policies and procedures for also monitoring.
12. Medication stock areas are inspected monthly by In-Patient Pharmacists.
13. Hazardous drug are stored in proper manner:
14. L1) Hazardous medications and pharmaceutical chemicals are stored separately following alphabetical system on low shelves as possible and in the original labelled containers.
15. L2) Flammables and volatile substances are stored in appropriate safety cabinets in well ventilated areas.
16. L3) The spill kits and personal protective equipment (PPE) are readily available.
17. L4) Pharmacy Staff involved in the handling of chemicals and hazardous medications who are attempting to conceive, pregnant, or breast feeding,  a structured process is in place to review potential exposure risks and offer alternative work assignment.
18. L5) Material safety data sheets (MSDS) for all available hazardous medications and pharmaceutical chemicals are available accessible to pharmacy staff.
19. L6) Eyewash station and emergency water shower (when available) are available where hazardous
20. Medications and pharmaceutical chemicals are located.

4.1.4 Ordering and Transcribing:

1. The Pharmacy Therapeutics committee develop the policies and procedures that guide the safe Prescribing, ordering and transcribing of the medications.

2. The organization defines the elements of a complete order or prescription and the type of orders that are acceptable to use.
3. All medication information is kept in patient medical records.
4. Attach policy with prohibited abbreviations not to be used to prevent medication error.
5. Establish policy for receiving verbal or telephone order that are countersigned by the prescriber within 24 hours.

4.1.5 Preparing and Dispensing:

A.    The pharmacy receives medication order electronically via computerize physician order entry to ensure that medications are given in right dose to the right patient at the right time

B.     Appropriate source of drug information is readily available online.

C.     Hospital assures that medication are prepared and dispensed in a clean and safe area that complies with laws and regulations.

D.    The medication order verification of the patient should have process and responsibilities in the policy and procedure of preparing.

E.     Pharmacist double checks the medication order before dispensing to prevent medication potential error.

4.1.6 Administration:

·   Only qualified individuals according to their job description, with the correct certification can administer medication.

·   Nurses focus on the ten rights of medication administration.

 

·   the qualified individual verify the following elements before administration:

1.      Identity of the patient.

2.      medication with the prescription or order

3.      time and frequency of administration with the prescription or order

4.      dosage amount with the prescription or order,

5.      Route of administration with prescription or order.

4.1.7 Monitoring:

•       All patients monitored on medication by nurses, resident doctors and clinical pharmacists when there is adverse or side effect  are reported.
•       Hospital record adverse drug reactions on the report and discuss in the pharmacy and therapeutics committee.
•         All patient medications are being evaluated during reassessment by physician, nurse and clinical pharmacist.
•      The evaluation should include the effect of the medication and the symptom or illness and/or significant lab result and anything else significant needing to be monitored. In addition to that ensuring evaluation of adverse effect s on patient in case the medication needs to be changed/modified or stopped a new medication order will be documented. if patient undergoing.

5.      Follow  up:

A.     The implementation of medication management plan is monitored through the use of measures related to medication management.The policy/plan is evaluated annually.

      Medication error reports are monitored.

6.      Responsibilities:

A.     Hospital leadership.

B.     Pharmacy and Therapeutic committee.

C.     Physician ,Pharmacist and Nurses

7.      Appendices:

A.     P&T team, term  of  reference

5. Reference:

5.1   Joint Commission Standards 7^th Edition 2017/ 7^th Edition April 2020.

5.2   CBAHI standards 2016