This document provides an overview of medication management at a healthcare organization. It describes the medication management and use cycle, which encompasses selecting, procuring, storing, ordering, transcribing, distributing, preparing, dispensing, administering, documenting and monitoring medications. The document outlines standards and requirements for each step of the medication management process to ensure it complies with applicable laws and regulations and meets patient needs. Key aspects covered include developing medication lists, reviewing prescriptions for appropriateness, safely preparing and dispensing medications, and recording medications in patient records. The goal is to apply quality principles to all medication processes for optimal patient outcomes.

1. Medication Management
And Use
April, 2013
Prepared by:
Mr. Mouad Hourani. Bsc, RN, MPh
Quality Improvement and Patient Safety Officer

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

3. 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.

4. Procuring
Storing
Monitoring
Ordering/
Documenting
Prescribing
Administering
Transcribing
Dispensing
Distributing
Preparing

5. Standard
MMU.1
• Medication use in the organization
complies with applicable laws and
regulations and is organized to meet
patient needs.
Standard
MMU.1.1
• An appropriately licensed pharmacist,
technician, or other trained
professional supervises the pharmacy
or pharmaceutical service.

6. Requirements
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.

7. MMU.1 - ME 2
Requirements
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

8. Requirements
MMU.1 - ME 3
Policies guide all phases of medication management and
medication use in the organization.
•All medication use cycle
related policies.

9. Requirements
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.

10. Requirements
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.

11. Requirements
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.

12. Requirements
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).

13. Requirements
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.

14. MMU.2
• An appropriate selection of medications for
prescribing or ordering is stocked or readily
available.
MMU.2.1
• There is a method for overseeing the
organization’s medication list and medication
use.
MMU.2.2
• The organization can readily obtain
medications not stocked or normally available
to the organization or for times when the
pharmacy is closed.

15. Requirements
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.

16. Requirements
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.

17. Requirements
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).

18. Requirements
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.

19. Requirements
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.

20. Requirements
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).

21. Requirements
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.

22. Requirements
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.

23. Requirements
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.

24. Requirements
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.

25. Requirements
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.

26. Requirements
MMU.2.2 – ME 3
Staff understands the processes.
•Education and
training supported by
attendance sheets.

27. MMU.3
• Medications are properly and safely
stored.
MMU.3.1
• Organization policy supports appropriate
storage of medications and applicable
nutrition products.
MMU.3.2
• Emergency medications are available,
monitored, and safe when stored out of the
pharmacy.
MMU.3.3
• The organization has a medication recall
system.

28. Requirements
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.

29. Requirements
MMU.3 - ME 2
Controlled substances are accurately accounted for
according to applicable laws and regulations.
•Narcotics policy based on
laws and regulations.

30. Requirements
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).

31. Requirements
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

32. Requirements
MMU.3 - ME 5
Organization policy defines how medications
brought in by the patient are identified and stored.
•Medication brought from
home policy.

33. Requirements
MMU.3.1 - ME 1
Organization policy defines how appropriate
nutrition products are stored.
•Storage policy describes
the way of storing
nutrition products.

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

35. Requirements
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.

36. Requirements
MMU.3.1 - ME 4
All storage is according to organization policy.
•A periodical inspection
report for all medication
storage areas.

37. Requirements
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.

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

39. Requirements
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.
•Crash cart policy.
•Monthly check list for crash
cart.

40. Requirements
MMU.3.3 - ME 1
There is a medication recall system in place.
•Medication recall policy

41. Requirements
MMU.3.3 - ME 2
Policies and procedures address any use of
medications known to be expired or outdated.
•Expired medication policy

42. Requirements
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)

43. Requirements
MMU.3.3 - ME 4
Policies and procedures are implemented.
•Return back logbook
• Observation

44. MMU.4
• Prescribing, ordering, and transcribing
are guided by policies and procedures.
MMU.4.1
• The organization defines the elements of a
complete order or prescription and the types of
orders that are acceptable for use.
MMU.4.2
• The organization identifies those qualified
individuals permitted to prescribe or to order
medications.
• Medications prescribed and administered
MMU.4.3
are written in the patient’s record.

45. Requirements
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.

46. Requirements
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.

47. Requirements
MMU.4 - ME 3
There is a collaborative process to develop the
policies and procedures.
•Pharmacy & therapeutic
committee TOR and MOM.

48. Requirements
MMU.4 - ME 4
Relevant staff are trained in correct prescribing,
ordering, and transcribing practices.
•Safe prescribing, ordering
and transcribing training and
education.

49. Requirements
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).

50. Requirements
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).

51. Requirements
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.

52. Requirements
MMU.4.1 - ME 2
Medication orders or prescriptions are complete per
organization policy.
•Incident reports.
•Chart review report.
• Audit reports.

53. Requirements
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.

54. Requirements
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.

55. Requirements
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.

56. Requirements
MMU.4.3 - ME 1
Medications prescribed or ordered are recorded for
each patient.
•Medication Ordering and
Prescribing Policy.
• Medication administration
record.

57. Requirements
MMU.4.3 - ME 2
Medication administration is recorded for each
dose.
•Medication Ordering and
Prescribing Policy.
• Medication administration
record.

58. Requirements
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.

59. MMU.5
• Medications are prepared and
dispensed in a safe and clean
environment.
MMU.5.1
• Medication prescriptions or orders are
reviewed for appropriateness.
MMU.5.2
• A system is used to dispense
medications in the right dose to the
right patient at the right time.

60. Requirements
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.

61. Requirements
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.

62. Requirements
MMU.5 - ME 3
Staff preparing sterile products are trained in
aseptic techniques.
•Aseptic
techniques
competency check

63. Requirements
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 crosscheck drug/drug interactions and drug allergies, (the
software is updated on an appropriate schedule).

64. Requirements
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)

65. Requirements
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).

66. Requirements
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.

67. Requirements
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.

68. Requirements
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.

69. Requirements
MMU.5.2 - ME 1
There is a uniform medication dispensing and
distribution system in the organization.
•Policy of
dispensing
medication.

70. Requirements
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.
•Policy of dispensing
medication.
•Surveyor
observation.

71. Requirements
MMU.5.2 - ME 3
Medications are dispensed in the most ready-toadminister form.
•Policy of dispensing
medication.
•Surveyor
observation.

72. Requirements
MMU.5.2 - ME 4
The system supports accurate dispensing.
•Policy of dispensing
medication.
•Indicator of
medication error.

73. Requirements
MMU.5.2 - ME 5
The system supports timely dispensing.
•Policy of dispensing
medication.
•Indicator of
medication error.

74. MMU.6
• The organization identifies those qualified
individuals permitted to administer medications.
• Medication administration includes a process to
MMU.6.1
verify the medication is correct based on the
medication order.
• Policies and procedures govern medications
MMU.6.2
brought into the organization for patient selfadministration or as samples.

75. Requirements
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.

76. Requirements
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).

77. Requirements
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.

78. Requirements
MMU.6 .1- ME 1
Medications are verified with the prescription or
order.
•Medications
Administration Policy.
•Competency
checklist.

79. Requirements
MMU.6.1 - ME 2
The dosage amount of the medication is verified
with the prescription or order.
•Medications
Administration Policy.
•Competency
checklist.

80. Requirements
MMU.6 .1- ME 3
The route of administration is verified with the
prescription or order.
•Medications
Administration Policy.
•Competency
checklist.

81. Requirements
MMU.6.1 - ME 4
Medications are administered on a timely basis.
•Medications
Administration Policy.
•Competency
checklist.

82. Requirements
MMU.6.1 - ME 5
Medications are administered as prescribed and
noted in the patient’s record.
•Medications
Administration Policy.
•Competency
checklist.

83. Requirements
MMU.6.2 - ME 1
Policies and procedures are implemented to govern
patient self-administration of medications.
•Self –
Administration of
Medications.

84. Requirements
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.

85. Requirements
MMU.6.2 - ME 3
Policies and procedures are implemented to govern
the availability and use of medication samples.
•Medication
samples policy.

86. MMU.7
MMU.7.1
• Medication effects on patients
are monitored.
• Medication errors, including near
misses, are reported through a
process and time frame defined
by the organization.

87. Requirements
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.

88. Requirements
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.

89. Requirements
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).
•Monitoring the effect
of medications policy.
•Incident reporting
policy.

90. Requirements
MMU.7 - ME 4
Adverse effects are documented in the patient’s
record as required by policy.
•Monitoring the
effect of
medications policy.

91. Requirements
MMU.7 - ME 5
Adverse effects are reported in the time frame
required by policy.
•Monitoring the
effect of
medications policy.

92. Requirements
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.

93. Requirements
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).
•Incident
reporting policy.

94. Requirements
MMU.7.1 - ME 3
Those accountable for taking action on the reports
are identified.
•Incident reporting policy.
•Medication safety committee
term of reference.
•Related Project FOCUS PDCA
members.

95. Requirements
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.