Medication Use

1. MEDICATION MANAGEMENT &
ITS USES (MMU)
Dr.Sushil Kumar mahato,
Pharm D

2. JCI Standards(6th Edition)
Chapters T
otal Number: 16
● Patient CenteredChapters: 8
● OrganizationManagementChapters:6
● Academic Medical CenterHospital Chapters: 2

3. JCI Chapters
The Academic Medical Center Hospital Standards are:
15.Medical Professional Education(MPE)
16.Human Subjects Research Programs(HRP)
The Patient Centered Standards:
1. International Patient Safety Goals (IPSG)
2. Access to Care and Continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
The Organization Management Standards are:
9. Quality Improvement and Patient Safety (QPS)
10.Prevention and Control of Infections (PCI)
11.Governance, Leadership, and Direction (GLD)
12.Facility Management and Safety (FMS)
13.Staff Qualifications and Education (SQE)
14.Management of Information (MOI)
Patient Centered Chapters
Organization Management
Academic Medical Center Hospital

4. INTERNATIONALP
ATIENTSAFETYGOAL(IPSG)
IPSG 1
Identify Patients Correctly
Use two identifiers; Name and UHID for both IPD and OPD. For
unknown/ comatose patient brought in ER identify as unknown 1
or 2
IPSG 2
Improve Effective Communication
(i)Use read back and verify policy for verbal order and laboratory
test result obtained on the phone and the process ( for handover
communication)
(ii)Comply to handover communication policy
IPSG 3
Improve the Safety of High-alert medications
Eg.. lnj. Pottassium Chloride, lnj. Sodium Chloride more than
0.9%, Inj. Magnesium sulphate equal to or more than 50% are not
to be stored in patient ward but stored only in the IP Pharmacy.
Look alike and sound alike medications are stored with proper
labeling with tallman method.

5. IPSG 4 Ensure Correct Site, Correct-Procedure, Correct Patient
Surgery Follow pre-surgical site marking with a
downwards arrow, pre-operative checklist and time out
in OT and Bedside procedures.
IPSG 5 Reduce the Risk of Health Care Associated
infections
Follow the WHO 2009 hand hygiene guidelines.
IPSG 6 Reduce the Risk of Patient Harm Resulting from falls.

6. ■ SampleMedicationsarenotallowedinthehospital
■ Homemedications arenotallowedinthehospital
■ Nursesareauthorizedtoadministerthemedication–noselfmedicationisallowed
■ Allmedications,whicharerecalledneedstobereturnedtopharmacyimmediately
MedicationProcess
 24hour’sIPpharmacyservicesareavailable.
 Emergencymedicinesareavailableandstored(FloorStock,CrashCart).
 Medicationordersaretobelegibleinspecifiedpageofdrugchart.
 Startanddiscontinuationorchangeorderofanydrughastobesigned,datedandtimed.
 Anywrongentryhastobecrossedoutwithasinglelineandsignederror.
 Effectofmedicationistobedocumentedintheprogressnotes.
 Medicationsareadministratedatstandardtimesotherthanstat orders.
 Nursessignature&timeismust onadministration.
 Labelallopeninusevialsandpre-filledsyringes.
Key Point

7. ● Allmedication errorto bereported.
● AllADRneedtobereportedinADRformforclinicalaudit.
● All orders(includingdiet and nursing stands cancelled when patient undergo surgery or istransferredout
ofICU’s).
● Allorderincludingdietaryorder,needtobewrittenafreshinthesituation.
StorageofMedicationandNutritionalProduct:
■ AllmedicinesandNutritionalproductsarekeptinSafeandClean,HumidityfreeEnvironment
■ RoomandRefrigeratorTemperaturetobemonitoredthreetimesdaily
■ DrugsshallbekeptunderlockinFloorStock,Bedsidelockersandemergencycrashtrolley
■ Expirycheckingonceinamonthanddailycheckingbynursing.Removebefore3monthsofexpiry
PrescriptionWriting
■ Individualswhoarepermittedareidentifiedtocarryouttheorders
■ Medicationsaretobewrittenlegiblyinspecifiedform,dated,timed&signed
■ Verbalordersarenotacceptableexceptinlifesavingsituations
■ Document“STOP”orderslegiblywithyoursignature,datedandtimedappropriately
DrugDispatch:
■ AllmedicinesarecheckedbyPharmacistbeforedispensing
■ Alldrugs–dispatchwithin120minutes&allemergencydrugs–dispatchwithin30minutes

8. Medicationerrorisanypreventableevent,thatmaycauseorleadtoinappropriatemedicationuseorpatientharm,whilethe
medicationisinthecontrolofthehealthcareprofessional,patientorconsumer
.
NearMissofMedicationError
AMedicationErrorwhichhasapotentialtocauseinjuryorharmandthatwasdetectedandcorrectedbeforeitreachedthepatient.
B. Adversedrugreaction(ADR):
AnADRisanynoxious,unintended,undesirableorunexpectedresponsetodrugthatoccursatdosesusedinhumansforprophylaxis,
diagnosisortherapy,excludingtherapeuticfailure.
NonDrugOrders
■ WriteallNonDrugOrdersinDoctorInstructionSheet
■ Pleaseprovide dateandtime
■ Writethediagnosisinthelabandradiologyrequisition
Nurseswilladministerthemedicinesaftercrosschecking
1. Rightpatient
2. Rightdrug
3. Rightdose
A. MedicationError
4. Righttime
5. Rightroute
6. Rightdocumentation

9. MEDICATION MANAGEMENT & ITS USES
STANDARDS: 7
• ORGANISATION & MANAGEMENT
• SELECTION & PROCUREMENT
• STORAGE
• ORDERING & TRANSCRIBING
• PREPARING & DISPENSING
• ADMINISTRATION
• MONITORING
MEASURABLE ELEMENTS: 83

10. STORAGE OF MEDICATIONS
• Medications and investigational medication agents are stored in the pharmacy according to the
manufacturer's recommendation. All medications are stored in designated areas which are sufficient to
ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
• Narcotics & Controlled Drugs: Controlled substances are stored behind a double lock.
• External Products: Disinfectants and drugs for external use are stored separately from internal and
injectable medications.
• Flammable Products: Flammable products are stored in a flammable safety cabinet.
• Refrigerated Products: Items requiring refrigeration are stored appropriately. Refrigerators are maintained
as follows:
 Temperatures must be kept within 36-46 degrees F or 2-8 degrees C.
• Frozen Products: Medications which are required to be stored frozen are stored in the freezer in the
Pharmacy. This freezer is equipped with temperature chart and alarm.

11. • Light Protection: All drugs, which require light protection while in storage, remain in the original package, in
closed drawers, or in a specially wrapped manner until the time of patient administration.
• Investigational Drugs: Investigational drugs are stored in locked, segregated cabinets.
• Cytotoxic and Hazardous Drugs: To prevent accidental contamination resulting in exposure of personnel to
hazardous substances, cytotoxic and hazardous drugs are stored in segregated areas which are clearly labeled.
• Unused Drugs: All pharmacy areas are routinely inspected for discontinued, outdated, defective or deteriorated
drugs and containers with worn, illegible, or missing labels. These drugs are returned to the Pharmacy Storeroom
where they are kept in a segregated area for return or destruction.
• High Alert Medications: High alert medications are identified by RED DOT labels which are placed on all
storage locations for high alert medications within the pharmacy.
• Look Alike/Sound Alike 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.
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12. SAFE DISPENSING OF MEDICATIONS
• Only full medicine strips would be dispensed & single/cut tablets would not be dispensed & taken back.
• Before dispensing (name of drug, strength, dosage, batch no., and expiry) any physical attributes are
checked by the pharmacist and matched against the name of the patient.
• Any discolored, visible impurity, expired medications shall not be dispensed by the pharmacy.
• The pharmacist has to check the strength, quantity, expiry of all drugs.
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13. HOSPITAL FORMULARY
• The Formulary process is a core stone of good pharmaceutical Management and safe use of medicines. It
consist of preparing, using and updating a formulary list (EML), a formulary manual and standard
treatment guidelines in a hospital. Choosing the most appropriate therapies and selecting the most cost
effective good quality products leads to better quality of care and more efficient, equitable use of resources.
• Changes in the formulary which may be made without committee approval are:
 Deletion of products no longer commercially available.
 Drugs recalled or withdrawn from the market.
 Change in commercial size.
 Addition of a new strength of a drug if the drug’s indication, side effects, etc. do not differ from that of the
formulary strength.
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14. MEDICATION RECONCILIATION
• Medication Reconciliation (MR) process is to reduce preventable medication errors on
admission to hospital, or transfer between hospital units and discharge to primary
care. The policy describes the steps to be taken:
 To ensure medicines prescribed on admission correspond to those that the patient was
taking before admission
 To identify any medication related causes for admission
 To communicate and record through appropriate documentation, any changes,
omissions and discrepancies in a patient’s medication

15. NARCOTIC DRUGS
 Storage in designated cabinets with Security.
 Ordering and Receiving of Controlled Substances should be done by licensed staff
only.

16. MEDICATION ORDERS
• Only registered medical practitioners are authorized to initiate medication orders.
• Prescriptions are verified for medication status, as well as for appropriateness of
use, dosage, route, allergies, drug-drug interactions and duplicate orders.
• Verbal orders follow the read-back or repeat-back procedure as per the policy.

17. ADMINISTRATION
• Medications given are verified and counter signed by two nurses.
• Check all the medications with proper route, dose, frequency, etc.
• HighAlert Medications are always stored separately.
• Multi- dose containers are labeled with proper instructions of type of diluents used and
date and time of preparation.
• Outdated and expired medications should be returned to the pharmacy.

18. MEDICATION ERRORS
"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the
medication is in the control of the health care professional, patient, or consumer.
Such events may be related to professional practice, health care products, procedures, and systems, including prescribing,
order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use."
• Any preventable event that may cause or lead to in inappropriate medication use or patient harm due to :
 Wrong time
 Wrong patient
 Wrong medication
 Wrong dose
 Wrong route
 Wrong documentation

19. TYPES OF MEDICATION ERRORS
• Prescription error
• Transcription error
• Dispensing error
• Administration error
• Monitoring error

20. Errors in medication administration often arise due to
combination of factors
• Poor communication
• Lack of knowledge
• Multiple interruptions
• Stress
• working conditions.
• Carelessness

21. %Analysis of Administration Error
0 10 20 30 40 50 60 70 80 90 100
39
COMMUNICATION GAP 4
New joined staff 13
Escalation not done 4
Lack of monitoring and supervisory mechanism from the TL/In charge for costly medicines 2
Administer the medication at the wrong time 4
Lack of drug information for the nurses 4
Patient file not taken to the bedside during administration. 11
Instead of half tablet, full tablet administered 2
Cross checking of prescribed dose before administration 6
Wrong Initial time 4
Handover was not taking without checking the medication 4
Staff nurse did not cross check the file before hand over
Documented before administration leads to missed dose
4

22. MEDICATION ERROR ANALYSIS
MONITORING
TRAINING
Medication Error
MANPOWER DOCUMENTATION
Only 2Clinical pharmacist
Only 3rd floor and 4th floor
have floor Pharmacist
Shortage of doctors
Infrequent audits
No over sight by
Nursing TL
Lack of knowledge & Staffs untrained on
Medication administration
Doctors are not trained on
medication reconciliation
Staffs not sensitised
about medication error
Documented before
administration
New Nursing staff
Joined
Wrong transcription
No Documentation
Wrong documentation
No over sight of Doctors
notes
Cross checking was
not happen
COMMUNICATION
Hand Over communication
was not proper
Communication Gap between
doctors and Nursing ;
Nursing , Pharmacist and
Doctors
PRESCRIPTION
Escalation not happen
Incomplete Prescription
Illegible handwriting
Special instruction was
not written
Shortage of Pharmacist
Pharmacist are not
trained

23. ADVERSE DRUG REACTION
• Response to a medicine which is noxious and unintended and which
occurs at doses normally used in human.

24. HIGH ALERT MEDICATIONS
• “High Alert Medications” are drugs that bear a heightened risk of causing significant patient
harm, when they are used in error.
• The top high-risk medications are:- Insulin, opiates, narcotics, injectable potassium chloride
concentrate (15%), intravenous anticoagulants (heparin), and sodium chloride solutions above
0.9 percent, sedatives and hypnotics, antipsychotics, antidepressants and antidotes.
• Special safeguards strategies should take to reduce the risk of errors and minimize harm. This
information about these drugs; using
strategies may include like providing mandatory patient education, improving access to
auxiliary labels and automated alerts; employing
automated or independent double checks when necessary; and standardizing the prescribing,
storage, dispensing, and administration of these products.

26. LASA DRUGS(Look Alike & Sound Alike)
• Many Drugs have same look and same sounds which leads to most of the
medication errors.
• Confusions are Illegible or poor handwritings, incomplete Knowledge of drug
names, newly available products, similar Packaging or labeling, similar clinical
use, similar strengths, similar dosage forms, etc.

27. • The goal is to develop a culture of patient safety and design systems that are
“Fault Tolerant”. So that when an individual error occur it will not cause any
harm to the patient.
• Feedback and Dissemination of Information can create an awareness of
errors that can improve system designs to reduce or eliminate errors.

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Thank You