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liza mamauag

on 16 May 2014

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STD. MMU.2: Medications for prescribing or ordering are stocked, & there is a process for meds not stocked or normally available to the hospital. (P)

Medications are properly & safely stored
Ordering & Transcribing

Prescribing, ordering, & transcribing are guided by policies & procedures.(P)


Medication use in hospital is

-to meet patient needs
-complies w/ applicable laws & regulations
-under the direction of licensed pharmacist (P)
Annual system review includes:
? well the system works as to:selection & procurement, storage, ordering & transcribing, preparing & dispensing
administrat'n & monitoring
monitoring from formulary changes
monitoring of med.errors & near misses
any education needs identified
consideration of new evidence-based practices

Intents & Measurable Elements:
a written doc. identifies how med. use is organized & managed
all setting, services, & staff managing med processes are included in the org. structure
a licensed pharmacist or qualified individual supervises the activities of pharmacy
at least 1 documented review of the med. management system w/in the last year
the pharmacy & medication use comply w/ applicable laws & regulations
appropriate drug info sources are accessible to those involved in med.use
Selection & Procurement
Ordering & Transcribing
Organization & Management
& Dispensing
Intents & Measurable Elements: (MMU.2)

there is a list of medications stocked in the hospital or readily available from outside sources
the process used to develop the list includes representation from those who prescribe & manage meds in the hospital
there i s a process to notify the prescribers for shortage or out-o-stock
for non-stocked meds: there is a process to approve & procure
there is a process for obtaining meds during the nig
STD MMU.2.1:

There is a method for overseeing the hospital's medication list & med.use
Measurable Elements: (MMU.2.1)

there is a method for overseeing med use in the hospital
staff involved in ordering, dispensing, administering, & patient-monitoring processes are involved in evaluating & maintaining med list
decisions to add or remove meds from the list are guided by criteria
newly added meds: a process to monitor how the drug is used & any unanticipated adverse events
the list is reviewed annually based on safety & efficacy info

Intent & Measurable Elements: (MMU.3)

evident for proper med. storage
meds are stored under conditions suitable for product stability, including meds stored on individual patient care units
controlled substances are accurately accounted for according to laws & regulations
meds & chemicals used to prepare meds are accurately labeled with contents, expiration dates, & warnings
conc.electrolytes are not stored in care units unless clinically needed but should be safeguard to prevent inadvertent administration
all med storage areas are inspected periodically
medications are protected from loss or theft throughout the hospital

STD. MMU.3.1
There is a process for storage of medications & nutrition products that require special consideration. (P)
Intent &Measurable Elements: MMU.3.
establish & implement a process of storing & controlling such products: - nutrition products - investigational drugs, & similar meds - sample meds - patient's own meds (POM)
STD. MMU.3.2
Emergency medications are available, monitored, & safe when stored out of the pharmacy. (P)
Intent: MMU.3.2
hospital plans the location of emergency meds & the meds to be supplied in these areas (quick access of its availability is vital)

emergency cabinets, carts, bags, or boxes can be used for this purpose
the hospital establishes a process to prevent abuse, theft, or loss, & also a process for replacing when used, damaged, or expired
Measurable Elements: MMU.3.2

emergency meds are available in the units where they will be needed to meet emergency needs
hospital establishes & implements a process for how emergency meds are stored, maintained, & protected from loss or theft
emergency meds are monitored & replaced on time
STD. MMU.3.3

The hospital has a medication recall system. (P)
Intent & Measurable Elements: MMU.3.3*

there is a medication recall system in place
hospital establishes & implements a process for use of meds known to be expired or outdated
also a process for the destruction of medications known to be expired or outdated
Intent & Measurable Elements: MMU.4*

the hospital establishes & implements a process of the following: -safe prescribing, ordering, & transcribing
for managing illegible prescriptions & orders, including measures to prevent continued occurence*
staff are trained in correct prescribing, ordering, & transcribing
patient records contain a list of medications taken prior to admission to be made available to the pharmacy & the patient's health care practioners
initial med orders are compared to the list of meds taken prior to admission

STD. MMU.4.1

The hospital defines the elements of a complete order of prescription. (P)

Intent: MMU.4.1

hospital defines the complete elements of a complete order or prescription -
the data necessary to accurately identify the patient
the essential elements of all orders or prescriptions

- when generic or brand names are acceptable or required

- whether or when indications for use are required on a PRN or other med order

- types of orders that are weight based or otherwise adjusted, such as children, frail elderly, & other similar populations
There are processes in place to manage:

med orders that are incomplete, illegible, or unclear
special types of orders, such as emergency, standing, or automatic stop, & any elements unique to such orders;
verbal & telephone med orders & the processes to verify such orders
Measurable Elements: MMU.4.1

the required elements of a complete med orders or prescriptions include at least through those mentioned intents (5)
the hospital develops & implements a process to manage:

- med orders that are incomplete, illegible, or unclear

- special types of orders (emergency, standing, automatic stop, & any elements unique to such orders
a process to monitor the completeness & accuracy of med orders & prescriptions
STD. MMU.4.2

The hospital identifies those qualified individuals permitted to prescribe or to order medications.
Intent & Measurable Elements: MMU.4.2

1 - only those permitted by the hospital & by relevant licensure, laws, & regulations prescribe or order med
specific knowledge & experience is required*
2- the hospital establishes & implements a process to place limits, when appropriate, on the prescribing or ordering practices of individual
3- physicians permitted to prescribe or order are known to pharmaceutical service

Medications prescribed & administered are written in the patient's record.
Intent: MMU.4.3

patient's record contains the ff:
* list of prescribed meds

*dosage &

* times the med was given

* "PRN" meds ( & if this info is recorded on a separate med form, it should be inserted in the patient's record at discharge or transfer
Measurable Elements: MMU.4.3

1- medications required or ordered are recorded in each patient
2- medication administration is recorded for each dose
3- medication info is kept in the patient's record or inserted into his or her record at discharge or transfer
Preparing & Dispensing

Medications are prepared & dispensed in a safe & clean environment
Intent & Measurable Elements of MMU.5

1- meds are prepared & dispensed in a clean & safe areas w/ appropriate medical technology, equipment, & supplies (ex. laminar airflow hoods)
2- med preparation & dispensing adhere to laws, regulations, & professional standards of practice
3- staff preparing sterile products are trained in the principles of med preparation & aseptic techniques (I.V, epidurals)
STD. MMU.5.1

Medication prescriptions or orders are reviewed for appropriateness. (P)
Intent: MMU.5.1
good med management includes 2 reviews of each prescription or order
1- the appropriateness of the med for the patient & his or her clinical needs performed at the time the med is prescribed or ordered

2- the verification at the time of administration that the med is exactly as ordered or prescribed

first review-> by licensed pharmacist or trained staff
a new appropriateness review when drug dosage or other factors changes
appropriateness review shall be done also when circumstances are not ideal ex. stocks from unit areas
- a trained administrating staff shall conduct review prior to administration when the same staff will administer the order
The process to conduct FIRST REVIEW prior to dispensing by a trained pharmacy staff:

a) the appropriateness of the drug, dose, frequency, & route of administration
b) therapeutic duplication
c) real or potential allergies or sensitivities
d) real or potential interactions between the med & other meds or food
e) variation from hospital criteria for use
f) patient's weight & other physiological info
g) other contraindications
only competent staff (pharmacist/nurse or other concerned staff) will conduct the appropriateness of review like:
- those with documented training in review process with supported reference materials, computer programs, & other resources

for Telephone order (when new med order), process are as follow: -
Telephone Order
for new medication order
second review may be conducted by pharmacist the next day or review by another trained physician
nurse shall write down the order and
the order
& conduct review
in circumstances in which formal review is not practical like:
emergency cases (like in OT or emergency dep't
or with oral, rectal, or injectable contrast in interventional radiology or diagnostic imaging
Review Process to consider:
there is a record file which contains all med administered except emergency meds & those administered as part of procedure. The record must be kept in pharmacy for formal REVIEW
Measurable Element: MMU.5.1

1- the hospital defines the patient-specific info required for an effective review process & should be made available in the pharmacy at all times
2- each prescription or order is reviewed for appropriateness prior to dispensing & administration & includes all required elements
3- there is a process to contact the individual who prescribed or ordered the med when questions arise
4- staff permitted to review orders or prescriptions are competent & are provided genuine references
5- review is facilitated by a record file & is made available to pharmact at all times
STD. MMU.5.2

A system is used to dispense medications in the right dose to the right patient at the right time
Intents & Measurable Elements: MMU.5.2

there is a uniform medication dispensing & distribution system in the hospital
after preparation, med not immediately given are properly labeled* (drug name, dose/concentration, date prepared & expiration date)
medications are dispensed in the most ready-to-administer form
the system supports accurate & timely dispensing

The hospital identifies those qualified staff permitted to administer meds
Intent & Measurable Elements: MMU.6

1- the hospital identifies those individuals, by job description or the priveliging process, authorized to administer meds
2- only those permitted by the hospital and by, relevant licensure, laws, & regulations administer meds
3- there is a process to place limits , when appropriate, on the med administration of individual *
STD. MMU.6.1

Medication administration includes a process to verify the medication is correct based on the medication prescription or order
Intent: MMU.6.1

the safe administration of med includes verifying the
a) med with the prescription or orde
b) time & frequency of administration w/ the prescription or order

c) dosage amount w/ the prescription or order
d) route of administration w/ the prescription or order
e) identity of the patient
Measurable Elements: MMU.6.1

1- meds are verified w/ the prescription or order
2- the dosage amount is verified w/ the prescription or order
3- meds are administered on a timely basis
4- meds are administered as prescribed & noted in the patient's record
STD. MMU.6.2

Policies & procedures govern medications brought into the hospital for patient self-administration or as samples. (P)
Intent: MMU.6.2

oversee meds use in a hospital as to sources & uses when not dispensed from the hospital like:
- meds brought in by patient or family
- medication samples
they should be well-known to the patient's physician & noted in the patient's record
there is control in med sample availability & how it is managed, used, & documented

Measurable Elements: MMU.6.2

1- the hospital establishes a process to govern patient-self-administration of meds
2- also a process to govern the management, use, & documentation of any meds brought into the hospital for or by patient
3- there a process to govern the availability, management, use, & documentation of med samples

Medications effect on patients are monitored
Intent & Measurable Elements: MMU.7
(collaboration for a purpose))

1- med effects on patients are monitored
2- med adverse effects on patient are monitored & documented *
3- the hospital establishes & implements a process that identifies those adverse effects that are to be recorded in the patient's record & those that must be reported to the hospital
4- adverse effects are documented in the patient's record as
5- adverse effects are reported as identified by the process in the time frame required
STD. MMU.7.1

The hospital establishes & implements a process for reporting & acting on med errors & near misses. (P)*
Intent & Measurable Elements: MMU.7.

1- the hospital establishes a definition for a med error & near miss (use a standardized format for reporting & educating staff)
2- the hospital establishes & implements a process fro reporting & acting on med errors & near misses *
3- those accountable for taking action on the reports are identified
4- the hospital uses a med errors & near misses reporting info to improve med use processes

From: Pharmacy Dep't
Team Leader: Ph. Jasser Saleh
Pharmacy Director
Full transcript