SHASTHA KIDNEY AND MULTISPECIALITY HOSPITAL

MADURAI

Document Name : POLICIES & PROCEDURES ON MANAGEMENT OF

MEDICATION

Document No. : NABH/SHCO/MKCTRI/MOM

No. of Pages: 17

Date Created: 01.04.2023

Date of Implementation: 01.04.2023

Designation: Medical Director

Prepared By:
Name :

Designation: NABH Coordinator

Responsibility of Updating: Name:
 CONTENTS

SI. No. Topics Page Number

1.0 MOM-1. Multidisciplinary Committee guides

pharmacy services and management of medication.
2.0 MOM-2. Medications are stored appropriately and
are available where required
3.0 MOM-3 . Medications are prescribed safely and
rationally.
4.0 MOM-4. Medication orders are written in a uniform
manner.
5.0 MOM-5. Medications are dispensed in a safe
manner.
6.0 MOM-6. Medications are administered safely.

7.0 MOM-7. Patients are monitored after medication

administration .
8.0 MOM–8. Narcotic drugs and psychotropic
substances are used in a safe manner
9.0 MOM-9. Implantable prosthesis and medical devices
are used in accordance with laid down criteria.
10.0
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MOM.1 : DOCUMENTED PROCEDURS GUIDE THE ORGANIZATION OF PHARMACY SERVICES AND

USAGE OF MEDICATION
1.0 PURPOSE:
To provide guidelines for the organization for Pharmacy services, management and usage of
Medication
2.0 SCOPE:
Pharmacy and other Patient Care Areas
3.0 RESPONSIBILTY:
Medical Superintendent, Doctors, Departmental Heads, Purchase Officer, and Pharmacists
4.0 ABBREVIATION:
NABH : National Accreditation Board for Hospitals and Healthcare providers
MOM : Management of Medication
5.0 REFERENCE:
NABH: Accreditation Standards for Hospitals ( 3RD edition), August 2022.
MOM.1: Documented policies and procedures guide the organization of pharmacy services and
usage of medication.
POLICIES:

1. Pharmacy is registered under Drug Control of India (Act)

2. Pharmacy shall comply with following Laws and Regulations. Drugs and Cosmetics, Narcotics and
Psychotropic substances etc.,
3. 12hours Pharmacy services are provided in our Hospital (8.30am to 8.30pm)
4. Arrangement is in place for issue of urgently needed drugs between 8.30pm to 8.30am for IP
5. Hospital drug formulary is approved by the pharmacy and therapeutic committee and all the drugs are
procured based on the list of drugs available in the formulary.
6. Request for non-formulary drug can be made with a request letter.
7. All the medications shall be stored at temperature specifications given by the manufacturer.
8. Look Alike & Sound alike medications shall be stored separately.
9. Expired, short expired & damage drugs shall be stored in a separate designated area.
10. Beyond expiry date medications are removed at regular intervals through an audit process carried out
every month and these are not used. The expired medicines shall be disposed off as per Biomedical
Waste Management Practices.

PROCEDURE & FORMULARY:

1. The copy of licenses shall be displayed in the Pharmacy at all times.

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2. Pharmacy is situated near the entrance and easily accessible from the outside of the hospital and will
work 12hrs a day x 6 days a week. (8.30am – 8.30pm)
3. Pharmacy will not purchase over-the-counter non-formulary medications, with the consent of MO.
4. Pharmacy may substitute generic equivalents of brand name drugs ordered.
5. Prescription from outside hospital to buy a medicine is usually not accepted. On Chief’s instruction such
drugs may be given after checking the prescription date, Doctor’s name and give to the patient for a
short period.
6. We follow the rules for the schedule drug. Register for scheduled drug is maintained. Such drugs are
registered will be issued as Schedule H and Schedule H1 drugs.
7. A multi-disciplinary Committee guides the formulation and implementation of these policies and
procedures. The committee – Representatives of major Clinical Departments, Administration and
include a Pharmacist and Nursing Superintendent.
8. Pharmacy services shall be responsible for proper Storage, Distribution and Safe Usage of Drugs.
Patient’s billing for medications and all policies and procedures regarding such activities are done
utilizing the Pharmacy software installed.
9. The Pharmacy will maintain adequate quantity of stock and shall purchase only quality drugs from
approved stockiest.
10. The Pharmacy should be kept neat and tidy. The medicine racks should be neatly arranged and free of
dust.
11. All drugs may be obtained based on the formulary list approved by Pharmaco Therapeutic Committee.
12. The Formulary copies are given to Chief Doctor, Duty Doctor, Ward, ICU, Dialysis, OT & OP Department
individually.

PURCHASE OF MEDICATIONS (PROCUREMENT):

Stock order is based on minimum order quantity level (reorder level is fixed as 10% of stock). Before placing
order, the actual stock of that drug is physically verified and compared with the computer stock. Purchase
order is prepared and given along with telephonic information. The ordered drugs will be received between
12.00 pm to 3 pm daily. The ordered drugs will be received in the office room and checked with regard to
the ordered quantity, batch number, expiry date and purchase rate in the bill. If there is any difference in
ordered quantity, batch number, expiry date and purchase rate, immediately returned to the supplier
through phone or mail. Once received the ordered quantity, the pharmacist come to the office, and they
will check the bill and quantity. The office staff will enter the purchase bill and drug will be shifted to
pharmacy and kept in the Pharmacy in the specified rack.

If there is any new drug / product needed, the DMO or chief will counter sign the particular drug order and
then ordered by Purchase In-charge / this will be ratified in the committee meeting subsequently.

If there is emergency drug needed, Purchase will be ordered with sign from the Chief and order will be
placed and steps will be taken to procure the drug with 2 hours.
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If any ordered drug is not available from the supplier, the alternative drug will be ascertained from the Chief
and re order will be placed.

Pharmacy will not purchase over-the-counter non-formulary medications.

1.1 Procurement & usage of implantable prosthesis:

a) We follow the rules and regulations of quality implant procurement.
b) The highlights of the principles for purchase of implants: 1) The retailer of the
implant supply, should have adequate experience in this field. 2) Pre-gamma
irradiated implants should not have any broken packages. 3) Implants should be
free of tampering and transported in a hygienic environment. 4) Additional
instrumentation required for the implantation should be supplied by the retailer.
5) Any damaged implants should be replaced. 6) The hospital should have
adequate stock of the implant at a given time.
c) There shall be a well-trained staff and operation room personnel who keep
constant vigil regarding safe and hygienic handling of these implants.
d) Counseling is provided to patients and (or) their close relatives regarding the
implants and various merits and demerits of using different type of implants, and
the approximate time of removal of these implants will be informed and also
recorded in case sheet / discharge summary.
e) The batch no, and serial no of the implantable prosthesis are recorded in the
patient’s medical record and Operation Theatre logbook. The batch stickers are
also affixed in the respective areas in the patient’s medical record.
f) Every patient undergoing surgery for introduction of an implant or device shall be
educated and oriented towards the safe usage and precautions to be taken by
the concerned treating and operating doctors; the precautions shall include the
aspects of non-usage of specific drugs, diet, restriction in travel, bathing etc.,
and reporting to the hospital in case certain specific symptoms are noticed.
g) The implants if removed will be safely disposed by the hospital, as per Bio
medical waste rules.

STORAGE OF MEDICATIONS:

1. All the drugs are stored as per the prevalent Laws and Regulations.

i. Pharmacy Act;
ii. Narcotics and Psychotropic substances Act;
iii. Drugs and cosmetics Act;
iv. Food and Drugs Act;
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STORAGE OF MEDICATIONS in pharmacy according the manufactures recommendation and as per

Government Recommendations. Good lighting is provided in the pharmacy to give good visibility of the
labels. Sound inventory control practices guide storage of the medications. Inventory shall be as directed
by department head.

All drugs storage racks should be clearly and legibly labelled. The racks are labelled alphabetically and the
medicines are stored in systematic manner. Drugs available with proper purchase reference shall only be
stored in the pharmacy premises.

Monitoring of all Refrigerated items will be done twice in a day and a record should be maintained. Any
variation has to be notified to maintenance Engineering Department. Nutrition item, disinfectant and drugs
for external use are stored separately from internal and injectable medicines.

The Purchase bill and stock should be in office after checking the Batch No, Expiry, Quantity and others and
also check by the Pharmacist and then issued to the pharmacy and stocked on designated places.

LOOK ALIKE MEDICATIONS:

Medicine with similar packing, appearance, colour should be kept separately in the racks and the list of
medicines should be labelled on the side of the cupboard. Medicines which have a potential for confusion
due to look alike drug names or packaging area identified and treated with extra precautions to prevent
errors. They are kept at appropriate racks of the drug storage cabin.

SOUND ALIKE MEDICATIONS:

Sound Alike drug medication with drug names that sound similar when the drug names are mentioned orally
should be stored separately and dispensed with extra care. These will be kept in a separate rack.

EXPIRED DRUGS & DAMAGED DRUGS:

Drugs shall not be kept in stock after the expiry date on the label. Contaminated or damaged drugs shall be
disposed immediately. The Pharmacist routinely checks the drugs storage areas for outdated or damaged
drugs.

Expired drugs found in the hospital wards, ICU, Emergency room, OT are sent to the pharmacy store one
month before expiry date for proper disposal. The mechanism for destruction and disposal will be as per
laid down norms and regulations.

MEDICATION SECURITY:

Responsibility for security rests with the Pharmacy in charge and other designated personnel for drugs kept
outside the pharmacy.
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EMERGENCY MEDICATIONS:

There is a separate rack for Emergency medicines, in which a list is displayed at the rack for easy
identification. The list be prepared in consonance with good clinical practices and is documented. A crash
cart is maintained in Emergency room, ICU, Post OP ward and in HD unit. It will help the organization to
store the emergency medications in the standardized manner. The rows and drawers have defined
medicines. No other drugs shall be kept stored with emergency drugs.

HIGH RISK MEDICATIONS:

High risk medications that bear a heightened risk of causing significant patient harm when they are used
without proper precautions. The consequences of an error are likely to harm the patients. These are
labelled separately with colour coding of the racks and labelled. The medicines are represented by the
acronym “PINCH”.

A – ANTIINFECTIVE
P – POTASSIUM & OTHER ELECTROLYTES
I – INSULIN
N – NORCOTICS (Opioids and other sedatives)
C – CHEMOTHERAPEUTIC AGENTS
H – HEPARIN AND ANTICOAGULANTS

OBTAIN MEDICATION WHEN THE PHARMACY IS CLOSED:

Outside the pharmacy hours, there is a method to obtain medication. List of commonly used drugs will be
prepared and minimum qty will be kept in emergency usage cupboard on daily basis, which will be kept in ICU in
separate cupboard with lock and key. Separate Dispensing Note will be maintained. Once the sold drugs will be
checked, billed and replaced on daily basis. The stock note contains date, time, drug name, qty, cost of the drug,
replace qty. The amount will be collected at the reception. The dispensing note contains Patient name, H.No,
billed drugs, amount and Signature of the Reception staff.

PRESCRIPTION OF MEDICATION: REQUIREMENTS OF PRESCRIPTION:

Each prescription or continuation prescriptions should be signed with Date, Time by the Doctor.

The following details should be contained in all prescriptions. The Prescription should be in capital letter on
Brand Name under generic name.

1. Patient’s Hospital Number.

2. Patient’s Name, Age, Gender.
3. Weight if needed
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4. Generic name of the Medicine

5. Dosage Regimen
6. Strength or Concentration of Drug
7. Quantity or Total Number of Doses required
8. Direction of Use
9. Route of Administration
10. Prescriber’s Signature, Name (Clinical Stamp if provided) Time, Date shall be mentioned. Doctor’s
Registration No.

Repeat Prescriptions shall be written on the same prescriptions form with date sign or they may be given
similarly signed fresh prescriptions.

In case of inpatient the Doctor who visits the patient’s during rounds may advice medications which should be
written down in the drug order sheet in the patient file.

The order / prescription should also be legibly written with details regarding dose, duration, mode and
frequency of administration etc., and duly signed with date & time.

The ward staff will advise the patients to procure these medicines from the pharmacy and keep it separately for
each patient. These medicines should be administered according to the Doctor’s orders by the nursing staff to
the inpatient. None other than qualified Doctor is permitted to prescribe medicines to a patient seeking
treatment at the hospital. Only the medicines required by that particular patient appropriate to his / her clinical
needs are to be prescribed in doses that meet their individual requirement for an adequate period of time and
at the lowest possible cost to them. When the patient’s are discharged the remaining medicines shall be handed
over to the patient’s relatives and they are instructed, how to use them at home.

If the medicines are not sufficient they are given fresh continuation prescriptions. Drugs not used will be
returned to the pharmacy.

In case DMO prescribes the medicine, as per oral order by consultant, the prescription will be counter signed by
the consultant in-charge within 12 hours

All prescription orders are written in uniform location in the medical records of patient. All medication orders
shall be clear legible and are dated & timed & signed.

VERBAL ORDERS:

In case of Emergency situation if the Doctor gives any verbal order’s or Telephonic order regarding medicine to
be administered to a particular patient, the staff nurse receiving the verbal orders should then read back the
order. Nursing staff are permitted to act upon verbal orders provided the order is fully understood. The
attending nurse shall remind the attending Doctor about the patient drug allergies as marked with Red Ink on
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the patient’s file so that patient does not receive the allergic drug. Oral order will be entered in Case sheet and
informed by MO / consultant within 12 hours.

1.0 Policy on safe dispensing of Medication

a) In case of contaminations, short expiry or expired drugs etc., drugs shall be recalled
as per the procedure.
b) All medications shall be verified at the time of receipt of drugs and the same shall be
checked for damages and contaminations.
c) According to the feedback from patients or staff, the pharmacy should have a recall
procedure if the medicine is contaminated or expired.
d) The order shall be screened for appropriateness of drug, dose, and frequency, route
of administration, therapeutic duplications, drug-drug interactions, allergies, and
formulary status. Labelling requirements (at a minimum, labels must include the
drug name, strength; frequency of administration (in a language the patient
understands) shall be documented and implemented by the organization.
e) All High risk medication orders are verified prior to dispensing.
f) Expiry dates shall be checked prior to dispensing

2.0 PROCEDURE ON SAFE DISPENSING OF MEDICATION:

a) While dispensing the pharmacist / staff must meticulously check and review the
following details:

1) The prescription received is screened for clarity, appropriateness, dose,

therapeutic duplications, drug-drug interactions, allergies, quantity and
formulary status.

2) If an order is incomplete, illegible, unclear the pharmacist will contact the

consultant to clarify or change the order.

3) Physical contents of the package should be checked to ensure that it is not

damaged.

4) Expiry date is checked.

5) After dispensing a prescription, the remaining drugs are arranged back in its
original place on the racks.

6) While dispensing and when a medicine strip is cut, care should be taken to
preserve the drug name, batch no. and expiry date. Loose, unidentifiable
drugs should not be left alone in the racks.
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b) Drug Recall:

1) On receipt of information about banned / discontinued medications, from

manufacturers / stockists / distributors / medical representatives concerned with
batch number, the same shall be retrieved from all locations in the hospital
where such medicines are in stock and shall be returned to the stockist,
distributors concerned.
2) Such retrieved medicines shall be quarantined in Pharmacy until the drug is
packaged and returned as per manufacturer’s instructions.
3) The Drug Recall Register shall be maintained in Pharmacy stores.
4) There shall be medications destruction system where all the expired / damaged
/ contaminated medications are destroyed periodically.

c) High Risk Medication Dispensing:

1) As an additional precaution, high risk medication orders are verified

prior to dispensing

2) The record in the register shall include the following details for each
receipt and issue:

a) Date; name & address of person from whom medicines received or to

whom supplied;
b) Quantity of medicines received or supplied;
c) Balance remaining;
d) Name of prescriber;
e) Signature of person making the entry;
f) Signature of person checking.
g) This record to be maintained by In-charge pharmacy and is responsible
for any irregularity.
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MOM / 5
MULTISPECIALITY HOSPITAL, MADURAI
Issue No. 01

PROCEDURE FOR MEDICATION Rev. No 00

ADMINISTRATION
Date 01.04.2023

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Policy on Medication Administration

1.1 All medications shall be administered as ordered by the physician, by an authorized health
care professional
a) All the medications shall be administered by the registered nurse based on the doctor’s
order; if there is any ambiguity in the prescription same shall be cross verified with the
concerned doctor either in person or through telephone.
1.2 The patient’s identity shall be verified by his / her MRD NO and Name (Father or Husband
name) prior to administration of the drug
1.3 The individual who administers the medication is responsible for ensuring that the right
medicine with right dose is administered to the right patient through the right route at the
right time, and the same is recorded in the drug chart.
a) Already prepared medications shall be labeled with the name of the drug, dosage,
timing, start date & time, sign of the personnel prior to preparation of the second
medication. This is applicable only for parenteral drugs
1.4 There shall be a uniform location for documenting the medication administration, the
medication chart to be used commonly for all IP areas ensuring continuity of medication
given.
a) All the entries in the chart shall include the:
 Date of entry
 Name of medication
 Dosage
 Route of administration
 Timing
 Name and signature of the person who has administered the medication.
b) In case of infusions, it shall capture the start time, the rate of infusion and end time
c) Self-administration of injectable drugs shall not be permitted in the Inpatient care areas.
1.5 A proper record is kept of the usage, administration and disposal of narcotics and
psychotropic medications
a) Usage of narcotics drugs and psychotropic substances are in consonance with Narcotic
drugs and psychotropic substances act.
b) Narcotic drugs and psychotropic substances shall be used as per Narcotic drugs and
psychotropic substances Act.
c) Only appropriate personnel shall handle these drugs in accordance with policies.
d) Weekly audits are conducted by Nursing Superintendent and Office In-charge.
e) Bill, Label, Dose and Expiry date shall be verified before administering to patient.
f) Doctor or nurse shall educate the patients and the family members about safe and
effective use of medication and about the food-drug interactions
2.0 PROCEDURE:
2.1 Procedures to ensure appropriate administration are: The label on the unit dose
package of medication matches the ordered medication on the medication administration
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MULTISPECIALITY HOSPITAL, MADURAI
Issue No. 01

PROCEDURE FOR MEDICATION Rev. No 00

ADMINISTRATION
Date 01.04.2023

Page Page 12 of 18

sheet/ order. Patient shall be identified prior to administration. The name and hospital
number on the medication administration sheet/order and on the medication, dosage
should be verified. The doctor’s orders written in doctor’s order sheet of the patient’s case
sheet shall be followed. The frequency and times of administering a particular drug and its
route of administration as noted in the orders shall be followed. It is the responsibility of
the staff administering the dose to verify medication and to confirm the appropriateness of
the dose, route, timing, and prior to administration. If the medication is from a multiple
dose vial, the individual who administers it must check the expiry date. The health care
professional who administers each dose of medication shall record the dose administered
on the patient’s medication administration record. The dosage administered shall be
recorded next to the charted time for orders with a dosage range. Standard medication
administration times will be observed for administration of medications.
1.6 In case of frequent IV administration of drugs, a cannula is inserted and retained in the vein
of one of the limbs (mostly the hands). All aseptic precautions are taken during the insertion of
the cannula. Proper care of the cannula has to be taken and the condition of the vein assessed
if the cannula has remained in the vein for more than 3 to 4 days. In case of inflammation along
the vein site the cannula has to be removed and reinserted elsewhere.
1.7 Injection at special sites like intra thecal, subconjunctival, lumbar etc are given by the doctor
only. All safe aseptic injection practices shall be followed and documented in the case notes
signed with time and date. Before administering drugs with a risk of producing allergic
reactions, a test dose of minute dose (0.1ml) of the drug is given intradermal and observed for
any undue reactions. This is documented and if found safe, only then should the full dose of the
medicine be given. All backup facilities should be ready nearby in case the patient develops
any untoward allergic reaction. In case of serious reactions like anaphylaxis, the doctor shall be
immediately called.
1.8 Oral medication should be administered by the nurse herself. This should be physically done
and confirmed that the patient has consumed the medicine fully in the prescribed dose. The
nurse should not hand over the medicine to the patient and instruct him to take it on his own
and leave the room. Each time a medicine is administered; the nurse should refer to the
doctors written orders and verify its dose, timing, route of administration and other instructions
to avoid mistakes. The time of administration and its intervals should also be checked. All the
medications and other treatment given to the patient should be promptly documented in the
patients case notes and signed by the nurse with time and date. The patient should be
instructed not to take any medicine brought from home without the knowledge or instructions of
the treating doctor or nurse. Drug administration time and initials by the Nurse will be
made in Black or Blue during daytime, and in red during Night time.

1.9 Self-administration of medication:

a) Patients own medications brought in by the patients who are on chronic therapy (e.g.
Conditions like Hypertension, Diabetes mellitus, Cancer, TB) shall be known to the
treating physician.
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Issue No. 01

PROCEDURE FOR MEDICATION Rev. No 00

ADMINISTRATION
Date 01.04.2023

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b) The patient shall be allowed to be self-administer the medications on certification of

treating physician and under the supervision of the nursing staff.
c) Such medications shall be entered in the patient’s treatment orders by the treating
doctor.
d) The nursing staff shall consult the orders and supervise the administration of the
medications after verification of the name of medication, dosage, time and route.
e) The administration of such medications shall also be recorded in patient’s record.

1.10 Medications brought from outside:

a) In case a patient brings medicine prescribed by the doctor at this hospital from an
outside organization, it should be shown to the treating doctor before the same is
administered.
b) Continuation of medicine prescribed by any other doctor before admission to this
hospital should get the permission of the treating doctor from this hospital.
c) All medications brought from outside should have a label, name, dose, expiry date and
shall be checked by doctor on duty / staff prior to administration.
 MOM.5 : PATIENTS ARE MONITORED FOR ADVERSE DRUG EVENTS AFTER MEDICATION
ADMINISTRATION

1.0 PURPOSE:
To ensure patient safety after the administration of medication creating a system for monitoring,
reporting and analyzing the medication errors and adverse drug reactions.

2.0 SCOPE:
Hospital Wide – All Inpatient care areas

3.0 RESPONSIBILTY:
1. Consultants, all Doctors,
2. Nursing Staff &
3. Pharmacy and Therapeutic Committee

4.0 ABBREVIATION:
NABH : National Accreditation Board for Hospitals and Healthcare providers
MOM : Management Of Medication
N.S : Nursing Superintendent
M.S. : Medical Superintendent
Dy. M.S. : Deputy Medical Superintendent
ICU : Intensive Care Unit
RR : Recovery Room
NICU : Neonatal Intensive Care Unit
KTR : Kidney Transplant Recovery Room
RMO : Resident Medical Officer

5.0 DEFINITION:
5.1. Adverse Drug Reactions: Adverse drug reaction (ADR) is any noxious, unintended,
undesirable, or unexpected response to a drug that occurs at doses used in humans for
prophylaxis, diagnosis, therapy of disease, or for modification of psychological function. This
definition is understood to exclude predictable, dose-related side effects due to drugs which
result in little or no change in patient management, and in particular, mild extra pyramidal side
effects due to neuroleptic drug therapy.
5.2. 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. Such events may be related professional practice, procedures, and systems,
including prescribing; communication; labeling, packaging, and nomenclature; dispensing;
distribution; administration; education; monitoring and use.
5.3. Types of errors: Order Error – Types of ordering errors include: inappropriate medication
selected, inappropriate dose, illegible order, duplicate order, order not dated/timed, wrong
patient/chart selected, verbal order misunderstood, verbal order not written in the drug chart,
wrong frequency, route, illegible writing, therapy duration, alert information bypassed or use of
nonstandard nomenclature or abbreviations.
5.4. Transcription error –Transcription involves both the orders that are manually transcribed onto
manual record (e.g. Drug chart). Types of transcription errors include: wrong medication,
time, dose, frequency, duration, rate patient/chart, verbal order misunderstanding, verbal orders
not entered into patient case sheet.
 5.5. Preparation/Dispensing Error – Types of preparation and dispensing errors include:
Inaccurate Labeling, wrong quantity, medication, dose, diluents, formulation, expired
medication, Pyxis refill error, and delay in medication delivery.
5.6. Administration Error – Types of administration errors include: Wrong patient, dose, time,
Medication, route, rate, extravasation (may be an ADR) and unauthorized dose given

6.0 REFERENCE:
1. NABH: Accreditation Standards for Hospitals (3th edition), August 2022.

7.0 POLICY:
7.1. On notice of an unusual incident regarding a medication nursing staff shall immediately
report to the consultant and the nursing staff.
7.2. A report is submitted to Pharmacy and Therapeutic committee chairman for corrective
actions.
7.3. If the patient has sustained serious illness as a result of the incident, Risk Management must
be notified. The medication error report includes: 1. Patient demographics ( name, location,
medical service); 2. Notation as to medical personnel who were notified of the incident (i.e.
physician); 3. Severity rating of the incident; 4. Accurate description of incident.
7.4. All patients shall be monitored after medication administration by enquiring every patient or
by documenting if the patient tells.
7.5. Indications of adverse drug reactions: Indications of an ADR include anaphylaxis,
arrhythmia, convulsions, hallucinations, shortness of breath, rashes, itching, hypotension,
dystonia, leukopenia, urinary retention, symptoms associated with neuroleptic malignant
syndrome, initial report of tardive dyskinesia, EPS related to non-antipsychotic drugs and
also includes true allergic (hypersensitivity) reactions and idiosyncratic reactions. All adverse
drug reactions shall be reported to the Director & Medical Superintendent. within 10- 15
minutes and the interventions observed will be documented in the patient case sheet. All
adverse drug reactions will be reported to the pharmacy and therapeutic committee in a
standardized format. All adverse drug reactions are intensively analyzed by Pharmacy and
Therapeutic committee and the corrective actions are taken based on the discussion.

8.0 PROCEDURE:
8.1. Procedure for the Identification and Review of any Medication Errors:
a. The inpatients who are administered different drugs need monitoring during their stay in the
hospital. This is of paramount importance in the case of patients undergoing treatment in the
ICU’s.
b. Certain drugs can produce serious immediate or delayed side effects. Patients with past
history of drug allergies shall be identified.
c. If drugs prone to produce allergic reactions, it should be done with caution. A small dose of
the drug is given intra dermal and marked with time, if any drug allergy is noted the main
dose administration is withheld and the doctor shall be informed.
d. Drug reactions producing cardiac, neurological, pulmonary, skin etc. side effects shall be
promptly identified and the concerned doctor should be promptly informed and remedial
action is taken.
e. All events and actions taken should be recorded by the concerned nurses in the patient’s
case sheet and signed with date.
 f. The medical superintendent and the nursing superintendent or the nursing supervisor shall
be notified in cases where wrong medications are administered to a patient, or there has
been negligence on the part of the nursing staff in following directions of drug administration
and necessary investigations should be initiated.
g. When Intra Venous (I.V) medications are given the nurse must be present near the patient
to monitor the progress or note any undue side effects. Starting and discontinuation of I.V
medication shall be done by the treating nurse and the details should be noted in the case
sheet with sign, date and time.
h. The nurse should enquire about the patient’s welfare from time to time after such treatment
and make sure that everything has been running smoothly.
8.2. Procedure for the Identification and Review of Adverse Drug Reactions (ADR):
a. Adverse drug events are defined and the staff nurse who has administrated the drug will be
reported to the doctor immediately and remedial actions will be taken.
b. Before the shift, the concerned staff should fill the prescribed ADR forms available in all
clinical areas. It should be given to the nursing superintendent through concerned nursing
supervisor.
c. Adverse drug events shall be collected and analyzed. Report and evaluate ADRs occurring
in the concerned Pharmacy & therapeutic Committee meetings.
d. These events shall then be analyzed by the committee to identify probable cause and
suggest and implement measures to prevent the same in future.
e. Policies are modified to reduce adverse drug events when unacceptable trends occur.
Labels, vials, packets of medicine due to which adverse event occurred shall be secured by
on duty staff nurse and given to committee.
f. Inform healthcare providers about ADRs to improve patient care.

MOM.6 : DOCUMENTED PROCEDURS GUIDE THE USE OF MEDICAL GASES

1.0 PURPOSE:
To provide patient safety in case of emergency situations.

2.0 SCOPE:
Hospital Wide – All Inpatient and Outpatient care areas

3.0 RESPONSIBILTY:
1. Consultants, all Doctors,
2. Nursing Staff &
3. OT technician

4.0 POLICY :
To Purchase Medical gas, Handling, Storage, Distribution Usage, Replenishment and
maintained records in accordance with legal requirements.

5.0 PROCEDURE:

Procurement of Medical Gas Cylinders:

 Procurement of Medical gas will be made according to the usage for the patients. OT in charge will
take care of the Stock level of the cylinders, he will issue the orders through phone. The frequency
 of ordering depends on the amount used but should be frequent enough to ensure adequate
supplies are always available.

 Written orders should be prepared so delivery notes and invoices can be matched.

 A record must be maintained for each type of medical gas cylinder kept at each
community setting showing:

 Maximum number of cylinders to be kept in cylinder store

  Dates and quantities received from suppliers

 Date and quantities issued to each location

 This record should be used for inventory control purposes and for establishing
maximum numbers of stock to be kept at the unit. It is very important that
accurate inventory control is maintained to avoid wastage or loss.

Handling of Medical Gas Cylinders:

 OT in charge will handle the bulk cylinders for replacing the empty cylinder with new
cylinder. In case of absence of OT in charge, another trained person will do the same.

 All staffs handling the cylinders are aware of the hazards through medical gases.

 Cylinders should be handled with care, never knocked violently or allowed to fall
over.

 Cylinders should only be moved with the appropriate size and type of trolley. When
cylinders are moved with apparatus attached, the cylinder valve should always be
closed.

 When in use cylinders should be firmly secured to a suitable cylinder support.

 Never roll cylinders along the ground as this may cause the valve to open accidently. It
may also damage the cylinder label and paintwork.

Storage of Medical Gas Cylinders:

 Medical gas cylinders must be stored separately from any non-medical gases in a
dedicated area.

 Cylinders should be stored under cover, preferably inside, in a dry, clean

secure lockable area.

 Cylinders must not be stored near stocks of combustible materials.

 Warning notices prohibiting smoking and naked lights must be posted at the
cylinder store that is clearly visible to all.
  The storage area must provide adequate space to allow segregation of
cylinders of different gases as well as full and empty cylinders. It must also be large
enough to allow easy access for stock examination and cylinder rotation.

 All cylinders should be stored in an upright manner by the use of safety chains.

 Gas cylinders must always be firmly secured and never left unsupported.

Distribution Usage of Medical Gas Cylinders:

 All Cylinder valves on both banks are open at all times (with the exception of the
emergency standby cylinders)

 as soon as the running bank cylinders are empty and the manifold changeover
has taken place, close the cylinder valves and replace with full cylinders

 open the cylinder valves on the reserve bank and complete leak checks

 Only appropriately trained practitioners should administer oxygen to patients

 Before administering oxygen to a patient, the practitioner must confirm the

identity of the gas, check the expiry date of the gas and ensure adequate
supplies of oxygen are available to maintain the flow rate prescribed

 Care must be taken to avoid confusing oxygen with medical compressed air.
Air flowmeters should be removed from wall outlets when not in regular use

 Appropriate monitoring and flow rate devices including pulse oximetry must
be used to achieve the target saturation prescribed

 Practitioners must regularly monitor saturation levels and adjust flow rates to
keep within the target saturation range

Accurate documentation of flow rates and target saturations achieved must

be recorded in the patient’s notes

Even if piped oxygen is available at the patient’s bedside, it is important that emergency
cylinders of oxygen available for transporting patients and/or for use in areas where piped
oxygen is not provided

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