mmu chapter - jcia 2013

Medication Management And Use

April, 2013

Prepared by: Mr. Mouad Hourani. Bsc, RN, MPh

Quality Improvement and Patient Safety Officer

Topics 1. Introduction. 2. Medication Management and Use Cycle. 3. Organization and Management. 4. Selection and Procurement. 5. Storage. 6. Ordering and Transcribing. 7. Preparing and Dispensing 8. Administration. 9. Monitoring.

Medication management encompasses the system and processes an organization uses to provide pharmacotherapies to its patients.

It is usually a multidisciplinary, coordinated effort of staff of a health care organization, applying the principles of effective process design, implementation, and improvement to the selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication therapies.

Procuring

Storing

Ordering/ Prescribing

Transcribing

Distributing

Preparing

Dispensing

Administering

Documenting

Monitoring

• Medication use in the organization complies with applicable laws and regulations and is organized to meet patient needs.

Standard MMU.1

• An appropriately licensed pharmacist, technician, or other trained professional supervises the pharmacy or pharmaceutical service.

Standard MMU.1.1

MMU.1 - ME 1 There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization.

•Medication Management Plan.

•P & T committee.

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MMU.1 - ME 2 All settings, services, and individuals who manage medication processes are included in the organizational structure.

•Pharmacy Scope of services

•Pharmacy Organizational structure.

•TOR of P&T committee

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MMU.1 - ME 3 Policies guide all phases of medication management and medication use in the organization.

•All medication use cycle related policies.

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MMU.1 - ME 4 There is at least one documented review of the medication management system within the previous 12 months.

•Review of Medication Management Plan through P&T meeting minutes.

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MMU.1 - ME 5 The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations.

•Laws and regulations related to medication management and use such as MOH, Narcotics Law. R

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MMU.1 - ME 6 Appropriate sources of drug information are readily available to those involved in medication use.

•Drug formulary available electronically or printed out and accessed to all healthcare providers.

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MMU.1.1 - ME 1 An appropriately licensed, certified, and trained individual supervises all activities. (Also see GLD.5, ME 1)

•Certifications and job description of the pharmacy director (employee file).

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MMU.1.1 - ME 2 The individual provides supervision for the processes described in MMU.2 through MMU.5

•Director job description.

•Pharmacy organizational structure.

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• An appropriate selection of medications for prescribing or ordering is stocked or readily available.

MMU.2

• There is a method for overseeing the organization’s medication list and medication use.

MMU.2.1

• The organization can readily obtain medications not stocked or normally available to the organization or for times when the pharmacy is closed.

MMU.2.2

MMU.2 - ME 1 There is a list of medications stocked in the organization or readily available from outside sources.

• Medication Formulary developed contains quantities and location within organization.

• Medication list developed contains quantities and location outside organization.

• Note: P&T committee minutes shows review of medications required as per scope of service.

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MMU.2 - ME 2 A collaborative process was used to develop the list (unless determined by regulation or an authority outside the organization).

• Pharmacy therapeutic committee TOR .

• Meeting minutes of approving the Drug formulary.

• Note: P&T committee will chose from MOH formulary the medication used as per hospital scope of service. R

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MMU.2 - ME 3 There is a process established for when medications are not available that includes a notification to prescribers and suggested substitutions.

• Drug Formulary policy (for not available medications).

• Medication Ordering, Prescribing, and Dispensing Policy. (for Suggested substitutions).

• Medication and Medical Supplies Procurement Policy (for not available medications). R

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MMU.2.1 - ME 1 There is a method for overseeing medication use in the organization.

•P&T committee TOR that includes overseeing the medication in the organization.

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MMU.2.1 - ME 2 Medications are protected from loss or theft throughout the organization.

•Policy of access to medication.

•Note: surveyor will observe the medication area if secured or not.

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MMU.2.1 - ME 3 Health care practitioners involved in ordering, dispensing, administering, and patient-monitoring processes are involved in evaluating and maintaining the medication list.

•Pharmacy therapeutic committee TOR (members are multidisciplinary).

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MMU.2.1 – ME 4 Decisions to add or to remove medications from the list are guided by criteria.

•Drug Formulary policy.

•P&T committee TOR.

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MMU.2.1 – ME 5 When medications are newly added to the list, there is a process or mechanism to monitor how the drug is used and any unanticipated adverse events.

•Newly added medication policy.

•Form of monitoring such medications.

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MMU.2.1 – ME 6 The list is reviewed at least annually based on safety and efficacy information.

•Drug Formulary policy.

•Meeting minutes of P&T committee.

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MMU.2.2 – ME 1 There is a process to approve and to procure required medications not stocked or normally available to the organization. (Also see GLD.3.2.1, ME 1).

•Policy of Medication and Medical Supplies Procurement.

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MMU.2.2 – ME 2 There is a process to obtain medications at times the pharmacy is closed or medication supply locked. (Also see GLD.3.2.1, ME 2).

•Policy and procedure that explains the process of getting medications out of pharmacy duty or the medication supply locked. R

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MMU.2.2 – ME 3 Staff understands the processes.

•Education and training supported by attendance sheets.

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• Medications are properly and safely stored.

MMU.3

• Organization policy supports appropriate storage of medications and applicable nutrition products.

MMU.3.1

• Emergency medications are available, monitored, and safe when stored out of the pharmacy.

MMU.3.2

• The organization has a medication recall system.

MMU.3.3

MMU.3 - ME 1 Medications are stored under conditions suitable for product stability.

•Medication Storage policy:

•Storage policy • Drug Stability policy

• Multi-dose containers policy

• Assure using temp. and humidity monitoring storing. R

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MMU.3 - ME 2 Controlled substances are accurately accounted for according to applicable laws and regulations.

•Narcotics policy based on laws and regulations.

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MMU.3 - ME 3 Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings.

•Medication dispensing policy (if ready to use).

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MMU.3 - ME 4 All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly.

• Pharmacy inspection form/checklist to monitor all medication storage areas.

• Storage policy

• Narcotic Policy

• Crash cart policy Re

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MMU.3 - ME 5 Organization policy defines how medications brought in by the patient are identified and stored.

•Medication brought from home policy.

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MMU.3.1 - ME 1 Organization policy defines how appropriate nutrition products are stored.

•Storage policy describes the way of storing nutrition products.

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MMU.3.1 - ME 2 Organization policy defines how radioactive, investigational, and similar medications are stored.

•Storage policy.

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MMU.3.1 - ME 3 Organization policy defines how sample medications are stored and controlled.

•Medication sample policy (in case of accepting to use).

•Preferable to prevent using such source of medication. R

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MMU.3.1 - ME 4 All storage is according to organization policy.

•A periodical inspection report for all medication storage areas.

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MMU.3.2 - ME 1 Emergency medications are available in the units they will be needed or readily accessible within the organization to meet emergency needs. (Also see GLD.3.2.1, ME 1, and MMU.2.2, ME 1).

•Crash cart policy.

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MMU.3.2 - ME 2 Organization policy defines how emergency medications are stored, maintained, and protected from loss or theft.


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MMU.3.2 - ME 3 Emergency medications are monitored and replaced in a timely manner in accordance with organization policy after use or when expired or damaged.


•Monthly check list for crash cart.

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MMU.3.3 - ME 1 There is a medication recall system in place.

•Medication recall policy

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MMU.3.3 - ME 2 Policies and procedures address any use of medications known to be expired or outdated.

•Expired medication policy

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MMU.3.3 - ME 3 Policies and procedures address the destruction of medications known to be expired or outdated.

•Expired medication policy. (to assure from companies that they are destructing the expired medications)

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MMU.3.3 - ME 4 Policies and procedures are implemented.

•Return back logbook • Observation

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• Prescribing, ordering, and transcribing are guided by policies and procedures.

MMU.4

• The organization defines the elements of a complete order or prescription and the types of orders that are acceptable for use.

MMU.4.1

• The organization identifies those qualified individuals permitted to prescribe or to order medications.

MMU.4.2

• Medications prescribed and administered are written in the patient’s record.

MMU.4.3

MMU.4 - ME 1 Policies and procedures guide the safe prescribing, ordering, and transcribing of medications in the organization. (Also see COP.2.2, ME 1; AOP.3, ME 1; and IPSG.2, ME 1).

•Medication Ordering, Prescribing, and transcribing Policy.

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MMU.4 - ME 2 Policies and procedures address actions related to illegible prescriptions and orders.

•Medication Ordering, Prescribing, and transcribing Policy.

•Not to dispense illegible prescription or order.

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MMU.4 - ME 3 There is a collaborative process to develop the policies and procedures.

•Pharmacy & therapeutic committee TOR and MOM.

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MMU.4 - ME 4 Relevant staff are trained in correct prescribing, ordering, and transcribing practices.

•Safe prescribing, ordering and transcribing training and education.

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MMU.4 - ME 5 Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners.

•Reconciliation policy and form (during admission).

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MMU.4 - ME 6 Initial medication orders are compared to the list of medications taken prior to admission, according to the organization’s established process.

•Reconciliation policy and form (during admission).

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MMU.4.1 - ME 1 Acceptable medication orders or prescriptions are defined in policy, and at least elements a) through i) are addressed in the policy.

•Policy of ordering, transcribing and prescribing.

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MMU.4.1 - ME 2 Medication orders or prescriptions are complete per organization policy.

•Incident reports.

•Chart review report.

• Audit reports.

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MMU.4.2 - ME 1 Only those permitted by the organization and by relevant licensure, laws, and regulations prescribe or order medications.

•List of Physicians are authorized to prescribe as privileged.

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MMU.4.2 - ME 2 There is a process to place limits, when appropriate, on the prescribing or ordering practices of individuals. (Also see SQE.10, ME 1)

•List of Physicians are authorized to prescribe as privileged.

•Policy of ordering and prescribing considering laws and regulations. R

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MMU.4.2 - ME 3 Individuals permitted to prescribe and to order medications are known to the pharmaceutical service or others who dispense medications.

•List of Physicians are authorized to prescribe as privileged which is communicated through MEMO to pharmacy.

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MMU.4.3 - ME 1 Medications prescribed or ordered are recorded for each patient.

•Medication Ordering and Prescribing Policy.

• Medication administration record.

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MMU.4.3 - ME 2 Medication administration is recorded for each dose.

•Medication Ordering and Prescribing Policy.

• Medication administration record.

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MMU.4.3 - ME 3 Medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer.

•Transfer form (includes medications 6 rights).

•Discharge form (includes medications 6 rights).

•To keep all medication orders and administration in patient’s file. R

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• Medications are prepared and dispensed in a safe and clean environment.

MMU.5

• Medication prescriptions or orders are reviewed for appropriateness.

MMU.5.1

• A system is used to dispense medications in the right dose to the right patient at the right time.

MMU.5.2

MMU.5 - ME 1 Medications are prepared and dispensed in clean and safe areas with appropriate equipment and supplies. (Also see PCI.7, MEs 1 and 2).

•Medication preparation and dispensing guideline/policy.

•Infection control policy regarding aseptic technique.

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MMU.5 - ME 2 Medications preparation and dispensing adhere to law, regulation, and professional standards of practice.

•Law and regulation or guideline for preparation and dispensing.

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MMU.5 - ME 3 Staff preparing sterile products are trained in aseptic techniques.

•Aseptic techniques competency check

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MMU.5.1 - ME 1 The organization defines the patient-specific information required for an effective review process. (Also see MCI.4, MEs 1 and 3).

• A policy of dispensing and administration that defines the information required for reviewing the orders.

• A record (medication administration record) for all medication administered to a patient (except emergency medications and those administered as part of a procedure).

• A computer software programs are used to cross-check drug/drug interactions and drug allergies, (the software is updated on an appropriate schedule).

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MMU.5.1 - ME 2 Apart from exceptions identified in the intent, each prescription or order is reviewed for appropriateness prior to dispensing and administration and includes elements a) through g) in the intent. Thus, each prescription or order is evaluated for appropriateness review.

•Dispensing and administration policy (considering the elements a) through g) as a process)

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MMU.5.1 - ME 3 There is a process to contact the individual who prescribed or ordered the medication when questions arise.

•Policy of dispensing and administration (showing as a process how to contact prescriber for any inquiry). R

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MMU.5.1 - ME 4 Individuals permitted to review orders or prescriptions are judged competent to do so.

•Competency in the review process (privileging).

•Education and training.

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MMU.5.1 - ME 5 Review is facilitated by a record (profile) for all patients receiving medications.

•Policy of dispensing and administration that identifies the accessibility of patient records which should be accessible through computer software. R

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MMU.5.1 - ME 6 Computer software, when used to cross-check drugs for drug/drug interactions and allergies, is periodically updated.

•Any document proving the computer software updates.

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MMU.5.2 - ME 1 There is a uniform medication dispensing and distribution system in the organization.

•Policy of dispensing medication.

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MMU.5.2 - ME 2 After preparation, medications are labeled with the name of the medication, the dosage/concentration, the date prepared, the expiration date, and the patient’s name.


•Surveyor observation.

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MMU.5.2 - ME 3 Medications are dispensed in the most ready-to-administer form.


•Surveyor observation.

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MMU.5.2 - ME 4 The system supports accurate dispensing.


•Indicator of medication error.

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MMU.5.2 - ME 5 The system supports timely dispensing.


•Indicator of medication error.

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• The organization identifies those qualified individuals permitted to administer medications.

MMU.6

• Medication administration includes a process to verify the medication is correct based on the medication order.

MMU.6.1

• Policies and procedures govern medications brought into the organization for patient self-administration or as samples.

MMU.6.2

MMU.6 - ME 1 The organization identifies those individuals, by job description or the privileging process, authorized to administer medications.

• Job description of registered nurse.

•Administration policy.

•Competency of registered nurses.

•Privileging of physicians. Re

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MMU.6 - ME 2 Only those permitted by the organization and by relevant licensure, laws, and regulations administer medications.

• Job description of registered nurse.

• Administration policy.

• Competency of registered nurses.

• Privileging of physicians.

• Medication administration record (staff signatures observation).

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MMU.6 - ME 3 There is a process to place limits, when appropriate, on the medication administration of individuals. (Also see SQE.13, MEs 1 and 2).

•Narcotic policy.

•Chemotherapy administration policy.

•Medication administration policy. R

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MMU.6 .1- ME 1 Medications are verified with the prescription or order.

•Medications Administration Policy.

•Competency checklist.

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MMU.6.1 - ME 2 The dosage amount of the medication is verified with the prescription or order.



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MMU.6 .1- ME 3 The route of administration is verified with the prescription or order.



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MMU.6.1 - ME 4 Medications are administered on a timely basis.



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MMU.6.1 - ME 5 Medications are administered as prescribed and noted in the patient’s record.



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MMU.6.2 - ME 1 Policies and procedures are implemented to govern patient self-administration of medications.

•Self –Administration of Medications.

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MMU.6.2 - ME 2 Policies and procedures are implemented to govern the documentation and management of any medications brought into the organization for or by the patient.

•Medications brought from home policy.

•Medication Reconciliation form.

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MMU.6.2 - ME 3 Policies and procedures are implemented to govern the availability and use of medication samples.

•Medication samples policy.

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• Medication effects on patients are monitored.

MMU.7

• Medication errors, including near misses, are reported through a process and time frame defined by the organization.

MMU.7.1

MMU.7 - ME 1 Medication effects on patients are monitored, including adverse effects. (Also see AOP.2, ME 1).

•Incident reporting policy (including adverse drug event and near miss).

•Monitoring the effect of medications policy. R

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MMU.7 - ME 2 The monitoring process is collaborative.

•Monitoring done through a sub committee including multi disciplinary members.

•Monitoring the effect of medications policy.

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MMU.7 - ME 3 The organization has a policy that identifies those adverse effects that are to be recorded in the patient’s record and those that must be reported to the organization. (Also see QPS.6, ME 3).


•Incident reporting policy.

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MMU.7 - ME 4 Adverse effects are documented in the patient’s record as required by policy.


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MMU.7 - ME 5 Adverse effects are reported in the time frame required by policy.


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MMU.7.1 - ME 1 A medication error and near miss are defined through a collaborative process. (Also see QPS.6, ME 4 and QPS.7, ME 1)

•Incident reporting policy that is approved by P&T committee.

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MMU.7.1 - ME 2 Medication errors and near misses are reported in a timely manner using an established process. (Also see QPS.7, ME 2).


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MMU.7.1 - ME 3 Those accountable for taking action on the reports are identified.


•Medication safety committee term of reference.

•Related Project FOCUS PDCA members.

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MMU.7.1 - ME 4 The organization uses medication errors and near misses reporting information to improve medication use processes. (Also see QPS.7, ME 3).

•Project FOCUS PDCA based on data collected through incident reporting.

•Actions taken by committee to improve process mentioned in meeting minutes. R

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mmu chapter - jcia 2013

Health & Medicine