Professional Documents
Culture Documents
Chapter IV
G ROUP M EMBERS
11040141019 11040141020
11040141022
11040141023 11040141024
Priyanka Wankhede
Abhishek Gupta Vinodkumar Meena
C HAPTER 4.
MOM.1
There is a documented policy and procedure for pharmacy services and medication usage. These comply with the applicable laws and regulations. A multidisciplinary committee guides the formulation and implementation of these policies and procedures
MOM.2
T HERE IS A HOSPITAL FORMULARY
Objective elements
A list of medication appropriate for the patients and organizations resources is developed The list is developed collaboratively by the multidisciplinary committee There is a defined process for acquisition of these medications
MOM.3
Medications are protected from loss or theft Sound alike and look alike medications are stored separately There is a method to obtain medication when the pharmacy is closed Emergency medications are available all the time Emergency medications are replenished in a timely manner when used
MOM.4
Medication orders are clear, legible, dated, named and signed Policy on verbal orders is documented and implemented The organization defines a list of high risk medication
Documented policies and procedures guide the safe dispensing of medications The policies include a procedure for medication recall Expiry dates are checked prior to dispensing Labeling requirements are documented implemented by the organization and
MOM.5 & 6
Medication is verified from the order prior to administration Dosage is verified from the order prior to administration Route is verified from the order prior to administration
Medication administration is documented Polices and procedures govern patients self administration of medications Polices and procedures govern patients medications brought from outside the organization
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MOM.7
Patient and family are educated about safe and effective use of medication Patient and family are educated about food-drug interactions
MOM.8
Patients are monitored after administration and this is documented Adverse drug events are defined
medication
Adverse drug events are collected and analysed Policies are modified to reduce adverse drug events when unacceptable trends occur
MOM.9
Objective elements Documented policies and procedures guide the use of narcotic drugs and psychotropic substances These policies are in consonance with local and national regulations
A proper record is kept of the usage, administration and disposal of these drugs These drugs are handled by appropriate personnel in accordance with policies
MOM.10
Objective elements Documented policies and procedures guide the usage of chemotherapeutic agents Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy
This shall preferably be a medical oncologist or a person who has been trained and has achieved competency in the same.
c)
Chemotherapy is prepared and administered by qualified personnel This shall preferably be staff who have received special training in preparing and administration Chemotherapy drugs are disposed off in accordance with legal requirements These shall be disposed off according to BMW management and handling rules 1998 or manufacturer's recommendation.
c)
Objective elements. Documented policies and procedures govern usage of radioactive or investigational drugs These policies and procedures are in consonance with laws and regulations This Interpretation refers to o AERB guidelines.
The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs Staff, patients and visitors are educated on safety precautions It should be demonstrated in practice. Appropriate signage should be used at all the places.
Objective elements. Documented policies and procedures govern procurement and usage of implantable prosthesis Selection of implantable prosthesis is based on scientific criteria and internationally recognized approvals The organization shall ensure that relevant & sufficient scientific data are available before selection. It shall also look for international or national notification for approval of the particular product. The batch and serial number of the implantable prosthesis are recorded in the patients medical record and the master logbook
Objective elements Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. The policies and procedures address the safety issues at all levels
Appropriate records are maintained in accordance with the policies, procedures and legal requirements.
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