FUH

1. 1.Purpose :
1.1 . To establish clear guidelines for handling patient’s own medications that patients had
brought from home to be use during hospital stay.
2.Definitions/Abbreviation’s:
2.1. Patients own medications: are any medications that belong to the patient and brought
into the hospital upon patients admission.
2.2. Medications Sample: A prescription or over the counter (OTC) drug not intended to be
sold, given by representative or their agent in it’s commercial packaging ,sample size, to
promote dug sales.
3. Policy:
3.1. patients are encouraged to bring all their current medications to the hospital at the
time of admission to ensure that an accurate medications history is taken on admission.
3.2. All medications proscribed for the patient during his /her hospitalization shall be
dispensed from inpatient pharmacy according to the unit dose system.
3.3. patients own medications can be used for the patient’s during his/her hospitalization if
it’s validity and stability can assured by pharmacy, only if :
3.3.1. Medications prescribed for a pre- existing Condition prior to hospital presentation
that are unavailable (Our of stock) non formulary items with no equivalent alternatives.
3.3.2. Complimentary medications :
3.3.2.1. Herbal, vitamins, minerals nutritional supplements , homeopathic medicines, or
any other natural products.
3.3.2.2. Birth control pills.
3.4. Patient’s own medications form(PHA 015 patients own medications form) shall be filled
to perform a risk assessment for medications brought in by the patient/ family that addresses
where and when medications was obtained how the medications was stored at home.
3.5. The patients are not allowed to self – administer his/her own medications or
medications ordered from the hospital.
3.6. Sample medications are not allowed to keep or administer in FUH premises.
Controlled Document
Patients own medications policy
Document #: FUH/ MMU/006

2. 4. Procedure
Procedure steps
4.1 Admission Reconciliation
4.1.1. A complete and accurate medication history shall be obtained and
document in EMR CPOE for all patients admitted to all inpatient unit by the
admitting physician.
4.1.2. The patients medication history is obtained from the patient, relatives
and / or care givers. Additional sources including medications bottles physician’s
prescriptions , and patients profile may be used to obtain a complete and
accurate active medication history.
4.1.3. In addition to the patients active medication history, the treating
physician shall take history of the following.
4.1.3.a. Strength, frequency, and route of administration of the current
home medications.
4.1.3.b. The date and approximate time the last dose of the medication
was taken, if known.
4.1.3.c. Any allergies.
4.1.4. If no information can be obtained from any source on home medication
history, the involved physician shall then document in EMR CPOE.
4.1.5. Inpatients pharmacist shall reconcile the medications admission orders
against entered home medications History. This is the mandatory requirements,
without the system doesn’t allow to proceed for any new medication order
processing and dispensing.
4.1.6. The inpatient pharmacist shall contact the ordering physician for
clarifications regarding discrepancies identified during the reconciliation
process. Discrepancies include when any home medication is omitted from
admission medication orders, when there is change in dosage of any re-ordered
home medications, when the admission orders may pose known therapeutic

3. contraindication, or when admission medications are prescribed against FUH
policy.
4.2 Transfer Reconciliation
4.2.1. Inpatient s medications orders automatically discontinued upon transfer
from one level of care to another .
4.2.2 The treating physician shall electronically order in EMR - CPOE the
transfer medications whenever a patient is transferred from critical care area to
regular wards or vice versa.
4.2.3. Clinical pharmacist/ inpatient pharmacist shall perform transfer
medication reconciliation by comparing the patient new ( post transfer)
medication order s against patients current Inpatient profile ( pre – transfer )
4.2.4. Clinical pharmacist/ inpatient pharmacist shall contact the ordering
physician that entered the transfer medication orders for clarifications regarding
discrepancies identified during the reconciliation process. Discrepancies include:
4.2.4.a. when any pre- transfer medication is omitted from post transfer
medication orders.
4.2.4.b. When there is change in dosage of any re- ordered pre- transfer
medications.
4.2.4.c. When any of the transfer orders may pose known therapeutic
contraindication.
4.2.4.d. When transfer medications are prescribed against FUH policy.
4.3 Discharge Medications Reconciliation
4.3.1. The treating physician shall enter take home medication for discharged
patients in EMR- CPOE and shall ensure that take home medications prescribed
include patients all current home medications that are still clinically indicated ,
in addition to all medications started during the hospital admission and that
continue to be clinically indicated upon discharge.

4. 4.3.2. The inpatient pharmacist shall perform the discharge medication
reconciliation by comparing the take home medications order against the
electronic medications patients profile created & updated during the hospital
stay.
4.3.3. Inpatient pharmacist shall contact the ordering physician of the take home
medications orders for clarifications regarding discrepancies identified during
the reconciliation process.
Discrepancies include:
4.3.3.a When any pre-discharge medication that is omitted from take
home medication orders.
4.3.3.c. When there is change in dosage of any pre-discharge medication
that are re- ordered as take home medications.
4.3.3 d. When any of the discharge medication may pose known
therapeutic contraindication.
4.3.3.d. When discharge medication are prescribed against FUH policy.
4.3.4. The treating physician shall:
4.3.4.a. Review the plan for discharge medications with the patient to
determine if the patient has an adequate medication supply at home.
4.3.4.b. Review stored medications that the patient brought in at the time
of admission, answer any questions and provide the patient with an electronic
complete list of medications prescribed & dispensed generated from inpatient
pharmacy if required.
4.3.5. Clearly explain to the patient when he/ she shall start 1 st dose of take
home medications.
4.4.6. Provide the patient an electronic prescription upon discharge.
4.4 Out patient Medication Reconciliation:

5. 4.4.1. During every clinic / ER visit , the treating physician shall ask patients
about their current home medication use, changes , addition, and compliance
and update home medication use.
4.4.2. The treating physician shall review patients use of over the counter
medications.
4.4.3. The treating physician shall electronically order medications that are
clinically indicated for the patient’s .
4.4.4 . The outpatient pharmacist must perform the reconciliation process as
follows:
4.4.4.a .For clinic patient s by comparing the medications recorded in the
electronic patients profile against the prescribed medications.
4.4.4.b. Outpatient pharmacist shall contact the ordering physician for
clarifications regarding discrepancies identified during the reconciliation process
Discrepancies include :
4.4.4.b.1. When medication renewal involves medication that are
omitted from patients active drug profile.
4.4.4.b.2. When there is change in dosage of any medications that is
active In patients drug profile.
4.4.4.b.3. When any of the ordered medications may pose known
therapeutic contraindication.
4.4.4.b.4. When medications are prescribed against FUH policy.
4.5. Monitoring and performance improvement
4.5.1. After completing the reconciliation process and clarifications of any
found discrepancies with the ordering physicians, the pharmacist shall record
electronically that medication reconciliation is completed.
4.5.2. Pharmacist shall report those found discrepancies as medication
reconciliation errors.

6. 5. Monitoring
Policy indicator measure ( if applicable) source of data responsible
6. Forms / Attachment/ Flow chart s:
N/A
7. Material/ Equipment
N/A
8. References/ Links to External sources:
8.1 The university of Kansas Hospital corporate policy.anual.
8.2. Fayette, Germantown, Le Bonheur,MECH, North, University.
8.3 Royal united Hospital Bath .NHS Trust
8.4. Joint commission international accreditation, standards for hospitals ,7th
edition,2021, medication management and use ( MMU)
9.Review History
Version. Change approval date. Changes approved by Changes

7. Medical Administration
Applicability: pharmacy, Nursing and medical staff.
1. Purpose
1.1. To establish appropriate guidelines to regulate the procurement ,
storage, and administration of medications on all floor s and unit at
FUH.
1.2 To provide safe and effective guidelines for medication
administration if special settings.
1.3 To outline individuals within the hospital authorized to administer
pharmaceutical preparations.
2. Definitions / Abbreviations:
2.1 . FUH Drug Formulary: A comprehensive list of all drugs approved by the
hospital pharmacy and thera6 committee, and which are available in the
hospital pharmacy.
2.2. Poly pharmacy: Simultaneous use of more than one medication having
very similar or identical mechanisms of action.
2.3. Medication: Any prescription medications, herbal remedies, vitamin’s ,
nutritional, over the counter drugs , vaccines, diagnostic and contrast agents
used on or administeredto persons to diagnose, to treat , or to prevent disease
or other abnormal conditions.
Radio active medication, respiratory therapy treatments parental nutrition,
blood derivatives , and intra – venous solutions .( Plain,with electrolytes and / or
drugs .)
2.4. EMR: Electronic medication administration Record.

8. 3. Policy
3.1. Medications cannot be administered without a verbal or electronic
physician order.
3.2. Medication orders must comply with proscribing guidelines of the FUH
policies and procedures and the ministry of health regulations.
3.3. Medication administration shall be performed by the following authorized,
licensed , and competent personnel.:
3.3.1. Registered Nurse
3.3.2. Physicians
3.3.3. Radiologist
3.3.4. Radiation Safety Officer ( RSO)
3.3.5. Anesthesiologist
3.3.6. Anesthesia Technician’s
3.3.7. Respiratory care practitioner
3.4. 7 rights verifications must be conducted by the administrator of the drugs.
3.5. Independent double check technique Shall be implemented on all
narcotics, controlled chemotherapeutic agents, and high alert medication;
verification by two ( 2) nurses on the system are required before administration
and during documentation. If the medication available in the patient specific bin
will be dispensed upon verification from the pharmacist before administration
by nurse .in case high alert medication, witness by 2 nursing staff is mandatory.
3.6. Medications shall not be left beside unattended Except self administer
medication.
3.7 Two unique identifiers patient medical Record Number and full name shall
be used to verify patient identification prior to medication administration.
3.8. Annual competency assessment or certification is required for all personal
administrating medications.

9. 3.9 . Drugs should be administered with in one (1) hour ½ hour before and ½
hour after, standard time unless specified otherwise by the physician, except for
patients with multiple intravenous medications.
3.10. Medications dispensed from pharmacy shall not be administered if
unlabeled, illegible, mislabeled, or expired container,and shall not be re labeled
.
3.11. Standing orders are allowed for normal saline flushing and sterile water for
humidity.
4. Procedure .
Procedure Steps
4.1 The treating physician shall enter the desired medication order
into yasasii in compliance with “ FUH / MMU 010 Guidelines for
Physicians Orders”
4.2 The Nurse will verify the physicians order and confirm any
unusual discrepancies, drugs, dose , frequency, route,and time.
4.2.1. Patients name and medical Record Number.
4.2.2. Medication with the physician order.
4.2.3.Time and frequency of administration with the order.
4.2.4. Dosage amount with the order.
4.2.5.Route of administration with the order.
4.2.6. Indication with PRN Medication orders.
4.2.7. Duration of treatment when applicable.
4.3 . Intravenous medications shall be prepared for administration in
the designated area in the medication room / IV room ,refer to policy
FUH/ MMU/ 018 Compounding sterile preparations.

10. 4.4. Health care personal must refer to the FUH drug formulary or
contact inpatient or outpatient dedicated phone lines (4810/4800) for
information concerning any medication with Which they are
unfamiliar with specific reference to.
4.4.1. Drug action
4.4.2. Dosage
4.4.3. side effects/ contraindication
4.4.4. Monitoring Requirements.
4.5. Health care personal shall adhere all rights of medication
administration.
4.5.1. Right patient
4.5.2. Right Medication/ Drug
4.5.3. Right Dose
4.5.4. Right route
4.5.5. Right Time
4.5.6. Right Frequency
4.5.7. Right Documentation
4.6. Staff administering oral medication shall witness what the patient
has taken the medication before leaving the room.
4.7.Drugs may only be omitted for the following reasons:
4.7.1. Physicians Order
4.7.2.Clinical justification by the physician
4.7.3. Patient Refusal

11. 4.8. Drug- Drug and Drug- food interaction and IV compatibility charts shall be
checked when needed, contact pharmacy if information needed is not available.
4.9. Polypharmacy is acceptable in the following situations:
4.9.1. When overlapping medications as part of the change from one
medication to another.
4.9.2. When PRN medication similar to the current one ,but requiring a
different route of administration or effect ,is needed.
4.9.3. When supported in the patient record by sound clinical rational or by a
written report consultation from a qualified physician.
4.9.4. When Two drugs are needed for the same indication but used on alternate
days.
4.10. Staff nurse shall document on HIS when a drug is omitted. She/ he must
justify the reason why the drug was omitted.
4.11. The administration of all medications will be documented on the HIS upon
administration.
4.12. Storage of all medications shall be in full compliance with policy “ FUH /
MMU/ 009 Management and security of medications stored outside pharmacy “
4.13.Authorization for specific administration
4.13.1. Radioactive material: licensed Radiologist and Radiation Safety Officer.
4.13.2. Contrast media: Nursing staff passing Annual competency and policy,
refer to “ AOP 043 Management and documentation of adverse drug reaction to
contrast Media “
4.13.3. Medication during surgery: Anesthesia Technician administer
medication under the supervision of the Anesthesiologist.
4.13.4. Respiratory therapy: Only inline inhalation therapy by licensed
Respiratory care practitioner passing annual RT Competency and

12. 4.13.5. Narcotics: Registered Nurses according to FUH Nursing policies and
procedures.
4.13.6. Patient controlled Analgesia & chemotherapeutic Agents: Nursing staff
passing competency.
4.14. Administration of medications in the injection room.
4.15. Central nervous system and neuromuscular blocking agents shall not be
administered in the injection room.
4.16. Standing orders :
4.16.1. Ordering and administering Normal saline for IV cannula and central
line flushing.
4.16.2. Assigned nurse / charge nurse is authorized to use the sterile normal
saline solution as standing order without having the physician entering the
order electronically.
4.16.3. For central line, the nurse / charge shall comply with the central line
Management policy FUH /PCI /022 “Management of central lines in FUH”
4.16.4. Ordering and administering sterile water for humidification of
oxygenation and mechanical ventilation and suctioning.
4.16.5. Assigned nurse / charge nurse is authorized to use the sterile water.
4.16.6. Solution as standing order without having the physician entering the
order electronically.
4.17.Refused / Omitted Dose
The nurse shall notify the treating physician about the refuse / omitted dose
status and documented that in the medication administration Record on the HIS
5. Monitoring
Policy indicator measure (if applicable ):
source of data :

13. responsible :
6. Forms / attachment/ flow charts:
6.1 N/A
7. Material/ Equipment
7.1. N / A
8. References/ links to external sources:
8.1 joint commission international accreditation, standards for hospitals,7 th
edition, 2021 , medication management and use
( MMU)
9. Review history:
Version:
Change approval date:
Changes approved by:
Changes:

14. 1.Purpose :
1.1. To establish clear guidelines for handling patient’s own medications that
patients had brought from home to be use during hospital stay.
2.Definitions/Abbreviation’s:
2.1. Patients own medications: are any medications that belong to the patient
and brought into the hospital upon patients admission.
2.2. Medications Sample: A prescription or over the counter (OTC) drug not
intended to be sold, given by representative or their agent in it’s commercial
packaging ,sample size, to promote dug sales.
2. Policy:
3.1. patients are encouraged to bring all their current medications to the
hospital at the time of admission to ensure that an accurate medications history
is taken on admission.
3.2. All medications proscribed for the patient during his /her hospitalization
shall be dispensed from inpatient pharmacy according to the unit dose system.
3.3. patients own medications can be used for the patient’s during his/her
hospitalization if it’s validity and stability can assured by pharmacy, only if :
3.3.1. Medications prescribed for a pre- existing Condition prior to hospital
presentation that are unavailable (Our of stock) non formulary items with no
equivalent alternatives.
3.3.2. Complimentary medications :
3.3.2.1. Herbal, vitamins, minerals nutritional supplements , homeopathic
medicines, or any other natural products.
3.3.2.2. Birth control pills.

15. 3.4. Patient’s own medications form(PHA 015 patients own medications form)
shall be filled to perform a risk assessment for medications brought in by the
patient/ family that addresses where and when medications was obtained how
the medications was stored at home.
3.5. The patients are not allowed to self – administer his/her own medications
or medications ordered from the hospital.
3.6. Sample medications are not allowed to keep or administer in FUH premises.

16. 4 Procedure
Procedure step
4.1 The treating physician shall check all medications brought from
home by the patient and shall instruct that he/ she are not supposed
to take any of them and return home if applicable.
4.2 In case the patient shall be using his own medication during his
stay , the physician shall order patients own medication by entering
on EMR under patients own medication category.
4.3 Nursing staff shall send these medications to the pharmacy for
verification, Reconciliation and labeling when needed along with filled
patients own medications form ( refer attachment 1) signed by the
treating physician and disclaimer for use of patients own medication
form( refer to attachment 2) Signed by the patient and guardian.
4.4 Pharmacy staff shall perform medication reconciliation, by
inspecting medicine physical integrity for any changes like color or
odor changes or any physical damage or due to improper storage
conditions. Expiry date ,identity and when and from where medicine
was obtained. Pharmacist reconciliation and verification shall be
documented by filling “ patients 0wn medication form” upon receiving
the patients own medication from the nursing staff . The form is to be
scanned and uploaded in EMR under patients profile for future
reference.

17. 4.5 Patients own medications should bear a label of patients two
identifiers ( patients full name medical Record Number) ward / clinic
name medicine name , strength, dosage form , expiry date , and batch
number. All labeling protocols for look alike sound alike ( LASA )
medicine, high alert medicine ( HAM ) And storage indicator labels
should be implemented. Medications shall be kept at designated
patients own medication bins of ADC or medication rooms in the
wards .
4.6. For semi- controlled and full controlled patients own medication:
exact quantity should be mentioned in the patient own medication
form , and to be received from the nursing team member , pharmacy
staff shall level the medicine with all patient and medicine details and
tag it by “ patients own medications “ label.
4.7 The treating physician shall make medicine orders using feature of
patients own medication in EMR . pharmacist will review the
appropriateness of the order and nurse shall retrieve the due dose
from the designated patients own medication bins in the wards as per
the validity of the order by the treating physician.
4.8 The nurse will administer to the patient and document that the
patient EMR
4.9 The nurse shall instruct the patient to send all in orders
medications back home with a caregiver or return at the time of
discharge.
4.10 The patients are not allowed to self administer his / her own
medications or medications orders from the hospital.
4.11. Sample medications are not allowed to keep or to administer in
FUH premises.

18. 4.12. Prior discharge, nursing staff shall prepare the remaining
patients own medication to be returned to the patient along with
patients home take medicine (discharge medicine)and proceed with
the medication hand over to the patients if applicable.
5. Monitoring
Policy indicator measure ( if applicable):
Source of data :
Responsible:
6. Forms / attachment/flowcharts:
6.1. Attachment 1: patients own medication form .
6.2. Attachment 2: Disclaimer for use of patients own medication.
6.3 Attachment 3: Patients own medicine label.
6.4. Attachment 4: Patients own medication process flowchart.
7. Material/ Equipment:
7.1 N/ A
8. references/ links to external sources:
8.1 joint commission international accreditation, standards for
hospitals,7 th edition, 2021 , medication management and use( MMU)
9. Review history
Version:
Changes approved by:
Changes: