3 Mom

Sr .No. 168/10+11, Behind Sadhana Girl’s High School, Keshav Chowk, D.P.
Road,
Malwadi, Sadesatara Nali, Hadapsar, Pune-411028
Telephone No. : 020 26737071/72, Email - info@yashhospital.com,
www.yashhospital.com
POLICIES & PROCEDURES ON MANAGEMENT

Document Name :
OF MEDICATION
Document No. : ENABH / YH / MOM /01-07
No. of Pages: 01 of 28
Date Created : 04.01.2018
Date of Implementation: 04.01.2018
Issue No. 02
Review No. 02 / 10.01.2019
Revision No. 00
Designation:
Prepared & Responsibility
Name : Mrs. Vaishali Lasanpure
of Updating :
Signature :
Designation: Executive Director
Approved By : Name : Dr. Shaila Suhas Kumbhar
Signature :
YASH HOSPITAL Doc. No. ENABH / YH / MOM /01
POLICY AND PROCEDURES ON

PHARMACY SERVICES & Page 2 of 32
USAGE OF MEDICATION
(MOM : 01) POLICY AND PROCEDURES ON PHARMACY SERVICES & 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 Director, Doctors, Departmental Heads, Purchase Officer, Stores Officer

and Pharmacists
4.0 ABBREVIATION:
NABH : National Accreditation Board for Hospitals and Healthcare providers

MOM : Management of Medication
5.0 REFERENCE:
NABH : Pre Accreditation Entry Level Standards for Hospitals, First Edition, April
2014.
MOM.1 : Documented policies and procedures guide the organization of
pharmacy services and usage of medication.
6.0 POLICIES:
1.1 POLICY ON PHARMACY STORAGE & USAGE OF MEDICATION
a) Yash Hospital pharmacy is registered under Drug Controller of India.
b) Pharmacy shall comply with the following laws and regulations: Drugs and
cosmetics act; Narcotics and psychotropic substance act.

USAGE OF MEDICATION
c) 24 hours pharmacy services is provided in Yash hospital. 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.
d) Request for purchase of a non-formulary medicine can be requested using the

Request for Non-Formulary Drug Form YM/OP/E1/FM/02
e) All the medications shall be stored at the temperature specifications given by the
manufacturer.
f) Look Alike and Sound Alike (LASA) medications shall be stored separately.
g) Expired, Short expiry & damaged drugs shall be stored in a separate designated
area
h) Beyond expiry date medications are removed at regular intervals through an audit
process carried out every 3 months and these are not used; the expired medicines
shall be disposed off as per bio-medical waste Management practices.
i) Selection of implantable prosthesis shall be based on scientific criteria and

national/internationally recognized approvals (Drugs and Cosmetics Act / FDA)
j) All implants / implantable prosthesis shall be procured through a defined process,

stored in sterile environment as recommended by the manufacturer and shall be
used as per guidelines provided
1.2 PROCEDURE:
1.3 Hospital has a pharmacy situated near the entrance and easily accessible from the
outside of the hospital and will work 24 hours a day, 7 days a week.
1.4 The copy of the licenses shall be displayed in the pharmacies at all times.
1.5 MEDICATION PROCUREMENT:
a) Pharmacy may substitute generic equivalents of brand name drugs ordered.


USAGE OF MEDICATION
b) If the physician has reasons to believe the generic drug is not equivalent, such
information should be documented and forwarded to the Medical Director through
respective pharmacies.
c) Pharmacy will not purchase over-the-counter non-formulary medications.
1.6 MEDICATION STORAGE:
a) Pharmacy Services shall be responsible for accurate drug storage, distribution,

appropriate and safe usage of drugs, patient billing for medications and all policies
and procedures regarding such activities.
b) The pharmacy will stock adequate quantity of quality drugs from approved stockist.
c) The pharmacy should be kept neat and tidy. The medicine racks should be neatly
well arranged and free of dust.
d) The refrigerators / freezers holding perishable medicines shall be in good working

condition.
e) Exposure to direct sunlight and heat should be prevented to the storage racks.
Medicines requiring cold temperature storage should be stored in A.C. rooms /
Fridge.
f) Expiry date nearing drugs should be identified and promptly removed from the
racks and sent back to the stockist for replacement. Fast moving drugs and
emergency drugs shall be stored in separate racks and its stock shall be monitored
daily.
g) Look alike or sound alike medicines shall be stored separately.
1.7 MEDICATION FORMULARY:
a) The stock of drugs should meet the requirements of the patients. Only drugs
approved for inclusion in the State and National Formulary are accepted.
b) Drug products classified by the FDA as ineffective will not be stocked by the
Hospital Pharmacy;
c) All drugs may be obtained based on the formulary list approved by Drug
Therapeutic Committee.

USAGE OF MEDICATION
1.8 PROCUREMENT & USAGE OF IMPLANTABLE PROSTHESIS:
a) Concerned doctors formulate and govern the rules and regulations of quality
implant procurement.
b) The highlights of the formulations are: 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 scratches and
transported in a hygienic environment. 4) Additional instrumentation required for
the implantation should be supplied by the retailer. 5) Any damaged implants like
scratches or slipped head screws should be replaced. 6) The hospital should have
adequate stock of the implant at a given time.
c) All implants are kept and stored in a sterile environment and re-sterilized once in 3
days if not used (gamma irradiated implants are exempted from this)
d) There shall be well trained staff and operation room personnel who keep constant
vigil regarding safe and hygienic handling of these implants.
e) All implants are sterilized through autoclaving at 121 degrees C for 30 minutes
except the gamma irradiated implants; Pre-sterilized or gamma irradiated implants
are checked for damages in packing. Before sterilization the implants are subjected
strict scrutiny to check for scratches, breakages and contamination.
f) All implants recovered from the patient’s body are given back to the patient himself
to prevent accidental or malafide re-use. In view of the patient’s health and well-
being counseling is provided to patients and (or) their close relatives regarding the
implants and various merits and demerits of using different type’s implants in their
bodies and the approximate time of removal of these implants from their bodies.
g) The batch no, and serial no of the implantable prosthesis are recorded in the
patient’s medical record and Operation Theatre / Cathlab Master logbook. The
batch stickers are also affixed in the respective areas in the patient’s medical
record.
h) Every patient undergoing surgery for installation 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 and reporting to the hospital in case certain
specific symptoms are noticed.

Page 6 of 32
PRESCRIPTION OF
MEDICATION
(MOM : 02) POLICY AND PROCEDURES ON STORAGE OF MEDICATION
1.0 PURPOSE:
To provide guidelines on storage of medicines.
2.0 SCOPE:
7.1. Pharmacy
7.2. All Medication storage areas
3.0 RESPONSIBILTY:
7.1. Medical Director

7.2. Pharmacy HOD
7.3. Pharmacists
4.0 ABBREVIATION:
7.1. NABH : National Accreditation Board For Hospitals and Healthcare providers
7.2. MOM : Management Of Medication
5.0 REFERENCE:
7.1. NABH: Pre Accreditation Entry Level Standards for Hospitals, First Edition, April
2014.
7.2. MOM.2: Documented policies and procedures guide the storage of medication.
6.0 POLICY:
7.1. All the drugs are stored as per the prevalent laws and regulations:
a) Pharmacy Act;
b) Narcotics and Psychotropic substances Act;
c) Drugs and cosmetics Act;
d) Food and Drugs Act;
7.2. Cyto tonic drugs are not stored in advance. They are ordered only after prior
intimation from the patients or Doctors.

Page 7 of 32
PRESCRIPTION OF
MEDICATION
7.3. Medication shall be stored as per the storage requirement specified by the
manufacturers, (these should address issues pertaining to temperature
(refrigeration), light, ventilation, preventing entry of pests / rodents and vermin’s) at
all location of storage such as OP pharmacy.
7.4. The storage of medications is done in alphabetical order of their Molecular names
in all the areas.
7.5. Medications shall be stored in a clean, well lit, and ventilated environment.
7.6. Refrigerator storage temperature shall be recorded 3 times a day in the stores and
in the pharmacy, whereas in other storage areas, it shall be recorded 3 times a day
and the same shall be verified and counter signed by the in-charge staff.
7.7. Medications shall be protected from loss and theft.
7.8. Sound alike and look alike medications shall be stored separately.
7.9. Emergency medicines should be available all time.
7.10. Emergency medications shall be replenished in a timely manner when used.
7.11. Inventory practices (like first in and first out (FIFO, ABC) shall be followed while
issuing inventory.
7.12. The medicine shall be stored by molecular name in an alphabetical order.
7.13. Organization shall conduct audits at regular intervals every quarter.
7.0 PROCEDURE:
7.1. Storage Of Medication: Medications are stored in the pharmacy/floor according to

the manufacturer's recommendation and as per government recommendations.
7.2. Good lighting is provided in the pharmacy to give good visibility of the labels.
7.3. Sound inventory control practices (first in and first out) guide storage of the
medications Inventory shall be as directed by department head. Expired, Short
expiry & damaged drugs shall be stored in a separate designated area.

Page 8 of 32
PRESCRIPTION OF
MEDICATION
7.4. All drugs storage container/racks shall be clearly & legibly labeled. The racks are
labeled alphabetically and the medicines are stored in a systematic manner
(alphabetically).
7.5. Drugs available with proper purchase reference shall only be stored in the
pharmacy premises.
7.6. Drug requiring cold chain shall be stored in refrigerator within temperature range of
2 to 8 degree C and rest of the drug shall be stored at room temperature. Medicine
requiring maintenance of cold chain, such as vaccines and sera are stored in
refrigerators and maintained in low temperature.
7.7. Monitoring of all refrigerated items will be done once in a day & a record will be
maintained. A daily record log of temperature readings will be maintained on the
outside door of the refrigerator .In case the variation is found repetitively, it will be
notified to Maintenance / Engineering department.
7.8. External Products disinfectants and drugs for external use are stored separately
from internal and injectable medications.
7.9. LOOK ALIKE / SOUND ALIKE MEDICATIONS: Medications which have the
potential for confusion due to look-alike or sound-alike drug names or packaging
are identified and treated with extra precautions to prevent error.
7.10. LIGHT SENSITIVE MEDICATIONS: Medications that are considered light-

sensitive, as labeled by their respective manufacturers, will be stored and
dispensed in a manner as to protect them from light. If the medication is
commercially available in a light-resistant package, the medication may be stored
on the shelf as it is.
7.11. EXPIRED DRUGS: Drugs shall not be kept in stock after the expiration date on the
label and no contaminated or deteriorated drugs shall be available for use. The
pharmacy/nurse routinely checks drug storage areas for outdated or otherwise
unusable drugs. Expired drugs found in the hospital wards, ICUs , Casualty , OT etc
are sending to the pharmacy store for proper disposition. The mechanism for
destruction and disposal will be as per laid down norms and regulations. In case of
non supervision, all drugs shall be stored under Lock & Key.
7.12. WARDS’ STOCK: Responsibility for control of floor stock medications within the
hospital wards and patient care areas rests with the Nursing Superintendent and

Page 9 of 32
PRESCRIPTION OF
MEDICATION
Ward in-charge Nursing staff. Floor Stock Medications will be maintained in

specific areas of the hospital, such as OT, Nursing Station, and some specific
medications in Consultant Chambers. These medications are intended for use by
Physicians and nurses with appropriate clinical privileges who are responsible for
ordering, preparing and administering drugs. Responsibility for the security of the
floor stock rests with the supervising nurse. Floor stock drugs are indented from the
Pharmacy by the ward in-charge nurse in predetermined quantities sufficient for
anticipated needs. Narcotic Floor stock are indented according to the policy on
controlled drugs.
7.13. MEDICATION SECURITY: All drugs stored shall be accessible only to authorized
personnel. Controlled drugs will be locked at all times prior to use. All pharmacies
will be locked at all times. Authorized personnel include pharmacists, and sales
assistance are admitted only when a pharmacist is present. When unattended, the
medication carts and medication rooms are to be locked. Medication security in
ancillary departments such as Imaging and other diagnostic labs is in locked
cabinets or drawers. Responsibility for security rests with the department Head or
designated personnel.
7.14. OBTAIN MEDICATION WHEN THE PHARMACY IS CLOSED: In case if the

hospital pharmacy is closed, there is a method to obtain medication. Since the
hospital has new pharmacy, which will be kept open for 24 hrs to ensure the
availability of medicines always.

Page 10 of 32
PRESCRIPTION OF
MEDICATION
(MOM – 03) POLICY AND PROCEDURES ON STORAGE OF MEDICATION
1.0 POLICY ON PRESCRIPTION OF MEDICATION
a) Only authorized person (treating consultant) shall prescribe medications, other than
the treating doctor who prescribes the drug shall not be accepted.
b) In case a Junior Doctor prescribes the medication, the prescription shall be counter
signed by the treating doctor or the Consultant incharge.
c) In case of verbal orders / telephonic instructions of the consultant, the same shall
be noted in the prescription by the pharmacist/staff nurse and counter signature
shall be obtained from the consultant within 24 hours. Read back policy shall be
followed.
d) All prescription orders are written in the letterhead of the Healthcare Organization
and shall contain the Registration number of the Consultant Doctor
e) All prescription orders are written in uniform location in the medical records of
patients
f) All medication orders shall be clear, legible and are dated, timed and signed
g) A list of high risk medication shall be defined and available in the organisation
2.0 PROCEDURE:
2.1 RATIONAL PRESCRIPTION OF MEDICATION:
a) None other than a 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 and their community.
b) When the patients are discharged the remaining medicines shall be handed over to
the patients/relatives and they are instructed on how to use them at home. If the
medicines are not sufficient they are given fresh continuation prescriptions. If some
of the medicines come as balance they can be returned to the pharmacy by the

Page 11 of 32
PRESCRIPTION OF
MEDICATION
patient and they will be refunded the money of the returned medicines with bill if
they are found to be in resalable condition.
2.2 REQUIREMENTS OF PRESCRIPTION:
a) Each prescription or continuation prescriptions should be signed with date / time by

the doctor.
b) The following details shall be contained in all prescriptions, minimum:
8.6.b.1 Patient’s MRD number;

8.6.b.2 Patient’s name & date of prescription;
8.6.b.3 Age and weight in case of paediatric patients;
8.6.b.4 Generic name of medicine;
8.6.b.5 Dosage regimen;
8.6.b.6 Strength or concentration of drug;
8.6.b.7 Quantity or total number of doses required;
8.6.b.8 Directions for use;
8.6.b.9 Prescriber’s signature, name (clinical stamp if provided), time and date shall be
mentioned.
8.6.b.10 Each medicines order must be individually signed;
c) The OP visiting patients shall be prescribed medicines in the particular OP

prescription form by the doctor with Name, Sign, time and date.
d) Repeat prescriptions shall be written on the same prescription form with date, sign
or they may be given similarly signed fresh prescriptions.
e) The patients OP number should be entered on each prescription form and the
details of the prescription is also entered on the patient OP card which will be
retained by the hospital.
f) In the case of inpatients the doctor who visits the patients during rounds in the
patient’s hospital room may advise medications which should write down in the drug
order sheet in the patients file. This 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 procure these medicines from

Page 12 of 32
PRESCRIPTION OF
MEDICATION
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 inpatients.
2.3 VERBAL ORDERS:
a) In the case of in patients, in emergency situations if the doctor gives any verbal
orders or telephonic orders regarding medicines to be administered to a particular
patient.
b) The individual accepting the verbal order shall record and then read back the order
in its entirety to the prescribing physician at the time the order is given,
documenting that the order was “read back” (RB).
c) Nursing staff shall tag all verbal orders with a “SIGN HERE & DATE” tag to alert the
physician of the need to sign the verbal order upon return to the unit.
d) Nursing staff are permitted to act upon verbal orders provided the orders contain
the appropriate information.
e) Verbal and telephone orders shall be signed or initialed by the prescribing

practitioner as soon as possible, not later than 24 hours.
f) When the ordering, if physician is unavailable, it is acceptable for another team

member or the attending staff to authenticate the verbal order.
g) Whenever there is doubt regarding a particular prescription (such as illegible

handwriting, wrongly written strength/dose or frequency, doubt regarding medicine,
etc.) or when a prescription is incomplete ( without sign, date, etc), the pharmacist
should promptly call the doctor and inform him and get it corrected without causing
inconvenience to the patient.
h) The attending nurse shall remind the treating doctor about the patients known drug
allergies as marked with red ink on the patients file so that the patient does not
receive that drug.
2.4 HIGH-RISK MEDICATION:
a) To identify potential high risk medications and to outline steps to prevent errors that
may result from confusion of these medications.

Page 13 of 32
PRESCRIPTION OF
MEDICATION
b) Avoid storing look-alike, sound-alike drugs next to each other (example: instead of
storing by generic name (e.g. vincristine and vinblastine) store drugs by brand
name (e.g. Oncovin and Velban). Limit high risk drug storage.
c) Minimize look-alike, sound-alike formulary combinations.
d) List of High risk medications:
S.N GENERIC NAME BRAND NAME

(A) CATEGORIES OF MEDICATION
1. ADRENERGIC AGONIST
1 ADRENALINE ADRENALIN INJ
2.ADRENERGIC ANTAGONISTS
CIPLAR 10MG /40MG TAB /INDERAL LA 20MG/40MG TAB
2 PROPANOLOL
20MG CIPLAR LA 20MG /40MG TAB
PROPRANOLOL +
3 MIGRABETA PLUS
FLUNARIZINE
METOLAR 5ML INJ/BETALOC INJ / BETALOC 25MG /
4 METOPROLOL TARTARATE
BETALOC 50MG
METOPROLOL +
5 AMTAS M 25MG / 50MG
AMLODEPINE
MET XL 12.5MG / 25MG TAB /50MG TAB/ METPURE XL
6 METOPROLOL SUCCINATE
12.5 / 50MG
METOPROLOL SUCCINATE
7 +RAMIPRILL +METOPROLOL MET XL R 25MG /2.5MG / MET XL R 50MG/5MG TAB
TARTARATE
8 LABETOLOL LOBET 20MG 4ML INJ
3. ANESTHETIC AGENTS
9 ETHER ANESTHETIC ETHER
10 KETAMINE HCL ANEKET 250MG/5ML/ANEKET 2ML INJ
11 PANCURONIUM NEOCURON INJ
12 SEVOFLURANE SEVORANE
13 ISOFLURANE ISORANE
14 FRERACRYLUM SEPGARD IV
15 MEPHENTERMINE TERMIN 10ML INJ
16 PROPOFOL NEOROF 10ML INJ / 20ML INJ
17 BUPIVACAINE HCL ANAWIN HEAVY INJ/ ANAWIN 0.25% / 5% INJ
LIGNOCAINE HCL WITH

18 LOX WITH ADRENALINE INJ
ADRENALINE
LOXICARD 50ML INJ / LOX 2% / LOX VISSCOUS / LOX

19 LIGNOCAINE
SPRAY
20 LIGNOCAINE HCL & LOX HEAVY 5% INJ

Page 14 of 32
PRESCRIPTION OF
MEDICATION
DEXTROSE
21 CLONIDINE ARKAMINE 100MG
4.ANTIARRHYTHMICS AGENTS
21 ADENOSIN ADENEON INJ/ADENOZ-6 INJ
AMIODON INJ /DURON INJ /CORDARONE
22 AMIODARONE
100MG/CORDARONE X 200MG TAB
23 DIGOXIN DIXIN INJ / LANOXIN 0.25MG TAB
24 DILTIAZEM DILZEM INJ
25 VERAPAMIL CALAPTIN 40MG /80MG /120MG
26 ISOSORBIDE DINITRATE SORBITRATE 5MG /10MG TAB
5.ANTITHROMBOTIC AGENTS
5.1 ANTICOGULANTS
27 WARFARIN WARF 1MG/2MG/ 5MG TAB
LOW MOLECULAR WEIGHT
28 ENCLEX 0.4MG INJ / 0.6MG INJ
HEPARIN
29 HEPARIN CAPRIN 25000IU / 5000IU INJ
30 RIVAROXABAN XARELTO 10/15MG/20MG
31 FONDAPARINUX SODIUM FONDAZEST 2.5MG
32 TICAGRELOR BRILINTA 90MG TAB
33 DABIGATRAN PRADAXA 150MG TAB
5.2 THROMBOLYTICS
34 TENECTEPLASE ELAXIM 40MG INJ
35 TENECTEPLASE RETEFLEX/ RETEFUSE 20MG INJ

36 STREPTOKINASE STPASE 1500000IU
37 UROKINASE U FRAG 500000 IU
5.3 GLYCOPROTEIN IIB / IIIA INHIBITORS
38 IV TIROFIBEN AGGRAMED INJ
6. CYTOTOXIC DRUGS
FLUOURACIL FLURACIL 250MG/500MG INJ
EPIRUBICIN EPITRHA 10/50MG INJ
OXALIPLATIN OXITAN 50/100MG INJ
PACLITAXEL PACLITRUST /BD TAXEL /PACFER 30/100/260/300MG INJ

39
CARBOPLATIN KEMOCARB 150/450MG INJ
CISPLATIN CISPLAT 10/50MG INJ
PEMTREXED PEMETA 100/500MG INJ
7 ORAL HYPOGLYCEMIC AGENT

40 GLICLAZIDE DIBEND 40MG / 80MG / GLYCINORM 40MG / 80MG
41 GLIMEPRIDE ZORYL 0.5/ 1MG / 2MG /3MG/ 4MG
42 PIOGLITAZONE PIOGLITAZ 150MG

Page 15 of 32
PRESCRIPTION OF
MEDICATION
ZORYL M 0.5MG/ M1/M2/M3 /M4TAB / GLIMISAVE

43 METFORMIN + GLIMEPRIDE M1/M2/M3 / M4TAB /GLUCONORM G 0.5MG/ G1/G2/G3
/G4TAB / GLYCOMET GP 0.5MG/ GP1/GP2/GP3 /GP4TAB
44 METFORMIN + GLIMEPRIDE GLYCOMET GP3 850MG
45 METFORMIN + GLICLAZIDE DIABEND M 80MG / GLYCINORM M 40MG /M80MG
GLIMISAVE M1 FORTE/M2 FORTE/M3 FORTE/M4FORTE
TAB /ZORYL M1 FORTE/M2 FORTE/M3 FORTE/M4FORTE
46 METFORMIN + GLIMEPRIDE
TAB /GLUCONORM G1 FORTE/G2 FORTE/G3
FORTE/G4FORTE TAB
METFORMIN + GLIMEPRIDE +
47 TRIVOLIB 1MG / 2MG / GLYCOMET TRIO 0.3MG
VOGLIBOSE
METFORMIN + GLIMEPRIDE +
48 TRIVOLIB FORTE 1MG / 2MG
VOGLIBOSE SR
49 METFORMIN + SITAGLIPTIN ISTAMET 50 / 500MG /
50 SITAGLIPTIN JANUVIA 50MG/ 100MG
51 METFORMIN + REPAGLINIDE EUREPA MF / 1MG / 2MG TAB
52 TENEGLIPTIN TGLIP 500MG / AFOGLIP 500MG
AFOGLIP M 500MG / TGLIP M 500MG/ ZITAMET PLUS
53 TENEGLIPTIN + METFORMIN
500MG / ZITAMET PLUS 1GM / AFOGLIP M 1GM
54 VOGLIBOSE ADVOG 0.2MG / 0.3MG /VOLIBO 0.2MG /0.3MG TAB
55 METFORMIN + VOGLIBOSE ADVOG M 0.2MG / 0.3MG / VOLIBO M 0.2MG / 0.3MG TAB
GLYCIPHAGE SR 500MG / 1GM / WALAPHAGE SR 500MG /
56 METFORMIN SUSTAIN R
1GM / GLYCOMET SR 500MG / 1GM
57 VILDAGLIPTIN + METFORMIN GALVUSMET 50/500MG
58 GLIBENCLAMIDE DAONIL 5MG TAB
METFORMIN +
59 DAONIL M TAB
GLIBENCLAMIDE
GLYCOMET 250/500MG/850/ GLYCIPHAGE 250/500MG
60 METFORMIN
TAB
GLIPIZIDE SUSTAIN
61 GLYNASE XL 5MG / GLYNASE XL 10MG TAB
RELEASE
62 GLIPIZIDE + METFORMIN GLYNASE MF
63 GLIPIZIDE GLYNASE 5MG / 10MG TAB
64 REPAGLINIDE EUREPA 0.5MG / 1MG TAB/EUREPA 2MG TAB
8 INOTROPIC MEDICATION
65 DOBUTAMINE DOBUMINE INJ
66 DOPAMINE HCL DOPMIN INJ
67 NOR-ADRENALIN NORLIN INJ
68 GLYCOPYROLATE PYROLATE INJ /LICOLATE INJ
NEOSTIGMIN +
69 MYO STIGMINE 5ML INJ /1ML
METHYLSULPHATE
9 INSULIN (SUBCUTANEOUS ,IV)

Page 16 of 32
PRESCRIPTION OF
MEDICATION
HUMAN ACTRAPID-40IU VIAL/FLEXPEN/PENFILL

HUMAN MIXTARD-40IU VIAL/FLEXPEN/PENFILL
70 INSULIN NOVOMIX-FLEXPEN/PENFILL
LANTUS-3ML PEN/100IU VIAL/PENFILL
HUMINSULIN N 40IU /HUMINSULIN R/HUMINSULIN 30/70
10 MODERATE SEDATION AGENT
71 DEXMEDETOMIDINE DEXTOMID 50KMG INJ / 100MG INJ
72 MIDAZOLAM MEZOLAM 10ML / KABIZOLAM 10ML INJ
10.NARCOTICS/ OPOIDS
73 FENTANYL CITRATE FENTANYL 2MLINJ
74 BUPRINORPHINE BUVALOR 10 PATCH
75 PENTAZOCINE TAZOWIN /6iPCOCiN INJ
11 NEUROMUSCULAR BLOCKING AGENT
76 SUCCINYLCHOLINE SUCOL INJ
77 VECURONIUM NEOVAC 4MG INJ
12.RADIOCONTRAST AGENTS
78 IOHEXOL (NON IONIC) OMNIPAQUE 350mg/ml
13. SEDATIVES
79 ALPRAZOLAM RESTYL 0.25MG /0. 5MG TAB
80 ATTRACURIUM ARTACIL 5ML INJ
81 CLONAZEPAM ZAPIZ 0.25MG / 0.5MG TAB
82 DIAZEPAM CALMPOSE INJ
83 HALOPERIDOL SERENACE INJ /SERENACE 0.25MG TAB
84 LORAZEPAM ATIVAN 1MG / 2MG TAB
85 LORAZEPAM LOPEZ 2ML INJ
86 CHLORDIAZEPOXIDE LIBRIUM 10MG / 25MG TAB
87 ZOLPIDEM ZOLFRESH 5MG/ 10MG TAB
88 ETIZOLAM ETIZOLA 0.25MG/0.5MG TAB
ETIZOLAM
89 ETIZOLA BETA 0.25MG / 0.5MG
+PROPRANOLOL
AMITRYPTILINE +
90 AMNURITE 5MG / AMNURITE 10MG/
MECOBALAMIN
13.Anti-Psychotic Drugs
91 ESCITALOPRAM NEXITO 5MG/10MG TAB
ESCITALOPRAM +
92 NEXITO PLUS 5MG
CLONAZEPAM
93 QUETIAPINE QUITIPIN 25MG/ 50MG
94 TRIHEXYPHENIDYL HCL PACITANE 2MGTAB
95 SERTRALINE SERTA 25MG/50MG TAB
96 DIVALPROEX DIVAA OD 250MG TAB / 500MGTAB
97 OLANZAPINE OLEANZ 2.5 MG/ 5MG / 7.5MG /10MG TAB
98 ARIPIPRAZOLE ASPIRTO 2MG / ASPIRTO 10MG
99 DULOXETINE DUZELA 20MG / 40MG TAB

Page 17 of 32
PRESCRIPTION OF
MEDICATION
OPIPRAMOL
100 OPIPROL 50MG / 100MG TAB
DIHYDROCHLORIDE
101 LEVODOPA + CARBIDOPA SYNDOPA 110MG TAB / SYNDOPA PLUS TAB
102 CLOMIPRAMINE CLONIL 10MG TAB
103 PROMETHAZINE PHENERGAN INJ/10MG/25MG TAB / PHENARGAN SYP
1
104 MAGNESIUM SULPHATE MAGNESIUM SULPHATE POWDER
MAGNEON INJ
15 DRUG USED DURING CARDIAC ARREST

ATROPIN SULPHATE 1ML/10ML/ 100ML / ATROPIN EYE
105 ATROPIN
DROP
106 CALCIUM GLUCONATE CALNAT 10ML
107 POTASSIUM CLHORIDE K-CL 10ML /KESOL SYRUP
108 SODIUM BICARBONATE SONATE 10ML/ SOBISIS FORT / SODAMINT TAB
109 VASOPRESSIN VPRESS INJ
110 ADRENALIN 1MG ADRENALINE 1ML INJ
16 ANTI EPILEPTIC DRUGS
111 FOSPHENITOIN FOSOLIN 150MG INJ
LEVIPIL 250MG/ 500MG / 750MG TAB /EPILIVE
112 LEVETIRACETAM
/250MG/500MG/750MG TAB/LEVEXX 500MG INJ
113 PHENITOIN EPTOIN 100MG / ER 300MG /SYRUP
17 VACCINES
114 TETANUS TOXOID TETANUS VACCINE
115 HEPATITIS B GENEVAC B 1MJ INJ/GENEVAC B 10ML INJ
116 ANTI RABIES ZUVIRAB /
INACTIVATED INFLUENZA
117 VAXIFLU
VACCINE (SWINE FLU)
18 ANTIALCOVOLIC DRUGS
118 METADOXINE ALCOLIVE 500MG

Page 18 of 32
SAFE DISPENSING OF
MEDICATION
(MOM : 04) POLICY ON SAFE DISPENSING OF MEDICATION
a) In case of contaminations, short expiry drugs, expired drugs etc., drugs shall be
recalled as per the procedure. Drugs to be sent back to pharmacy and informed
about this status in written to In-charge.
b) All medications shall be verified by the Departmental Head at the time of receipt of
goods 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) In case of any such incidence, same shall be returned back to the pharmacy along
with the bill (batch and serial number).
e) 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.
f) All High risk medication orders are verified prior to dispensing.
g) Expiry dates shall be checked prior to dispensing
1.0 PROCEDURE ON SAFE DISPENSING OF MEDICATION:
a) While dispensing the pharmacist / staff must meticulously check and review the
following details:
1) The prescription made by the doctor is checked to ascertain whether the doctor
works in this hospital or outsider;
2) The order must be signed by a Staff nurse or consultant.
3) The order must be complete to include name of medication, dosage, route of

administration, frequency.

Page 19 of 32
SAFE DISPENSING OF
MEDICATION
4) The order is screened for clarity, appropriateness, dose, therapeutic duplications,

drug-drug interactions, allergies, quantity and formulary status.
5) If an order is incomplete, illegible, unclear the pharmacist will contact the consultant
to clarify or change the order.
6) Physical contents of the package should be checked to ensure that it is not

damaged.
7) Expiry date is checked.
8) After dispensing a prescription the remaining drugs are arranged back in its original
place on the racks.
9) While dispensing, 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 counter
b) DRUG RECALL:
1) On receipt of 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 stockiest, 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:


Page 20 of 32
SAFE DISPENSING OF
MEDICATION
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.
3) THE DANGEROUS DRUGS REGISTER ENTRY MUST RECORD THE

FOLLOWING DETAILS:
a) Date;
b) Time;
c) Patients name;
d) Medical record number;
e) Amount administered;
f) Amount discarded (if part ampoule administered);
g) Balance remaining;
h) Signature of person making the entry;
i) Signature of person checking;
j) Name of the prescriber.
POLICY AND PROCEDURES

Page 21 of 24
FOR
USAGE OF RADIOACTIVE DRUGS
1.0 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 shall be verified by his / her MRD NO and 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.
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, 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.

Page 22 of 24
FOR
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) Narcotic and psychotropic medicines shall be issued only on registered medical

practitioner’s prescription.
e) The Narcotics shall be stored under double lock and key to ensure its rational
usage throughout the hospital.
f) Other than narcotic drugs, no items are permitted to be stored in the narcotic drug
cupboard including money.
g) A proper record of its uses, administration and disposal shall be maintained at all
the places wherever narcotic drugs are stored.
h) Weekly audits are conducted by Medical Superintendent and chief pharmacist
1.6 Drugs bought from outside the organisation are not allowed. In case of non-
availability of some drugs, this may be allowed.
a) Patients own oral 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 and will be allowed to administer to the patient
under the supervision and certification of treating physician, such medications shall
also be recorded in patient’s record
b) Bill shall be photocopied and attached to the Patient’s case sheet in such case.
c) Bill, Label, Dose and Expiry date shall be verified before administering to patient.

Page 23 of 24
FOR
d) 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 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.
1.7 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.
1.8 Injection at special sites like intra thecal, subconjuntival, lumbar etc are given by
the doctor or by trained technicians. 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

Page 24 of 24
FOR
any untoward allergic reaction. In case of serious reactions like anaphylaxis, the
doctor shall be immediately called.
1.9 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.
1.10 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.
b) The patient shall be administered by 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.
1.11 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.

Page 25 of 24
FOR
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.
d) The nursing staff would preserve the medical bill along with the medical records.
1.0 POLICY:
1.6 All patients shall be monitored after medication administration to verify that the
medication is having the intended effect and also to detect any near misses,
medication errors and adverse drug reactions.
1.7 Critical areas such as the ICU etc. shall require close monitoring of the patient
every hour or earlier as per the treatment requirements.
1.8 The monitoring shall be done through collaborative means involving the Intensivist,
RMOs and Nurses.
1.9 Medications, as well as dosages, shall be adjusted if required based on the

observations.
2.0 PROCEDURE:
1.6 PROCEDURES TO ENSURE APPROPRIATE PATIENT MONITORING AFTER

MEDICATION:
a) The medication administered is noted in the medication chart by the nursing

staff.
b) Thereafter, all the charts are maintained periodically to ensure that the
medication is having the intended effect on the patient.
c) The different charts to be maintained are:
 Medication
 Temperature, pressure and heart rate (TPR)
 Intake – Output
 Nurses’ notes

Page 26 of 24
FOR
d) In the intensive care areas, the Intensivist is responsible to ensure that the
patient condition is stable after medication administration.
e) In the wards, the RMOs are responsible to ensure that the patient condition is
stable after medication administration.
f) Any variation in the patient condition during the monitoring is immediately

notified to the concerned treating doctor either directly by the nursing staff or
RMO whichever appropriate in the given setting.
(MOM : 06) POLICY AND PROCEDURES FOR REPORTING OF NEAR MISSES, MEDICATION
ERRORS AND ADVERSE DRUG EVENTS
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
ICU : Intensive Care Unit
RR : Recovery Room
RMO : Resident Medical Officer

Page 27 of 24
FOR
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, contraindications, 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: Pre Accreditation Entry Level Standards for Hospitals, First Edition, April 2014.
2. MOM.6 Adverse rug events are monitored.

Page 28 of 24
FOR
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 consultant N.S.
/ M.S. / Dy. M.S. 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.

Page 29 of 24
FOR
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 along with 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.

Page 30 of 24
FOR
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.


Page 31 of 24
FOR
(MOM – 07) POLICY AND PROCEDURES FOR USAGE OF RADIOACTIVE DRUGS

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Sr .No. 168/10+11, Behind Sadhana Girl’s High School, Keshav Chowk, D.P.

POLICIES & PROCEDURES ON MANAGEMENT

Document No. : ENABH / YH / MOM /01-07

Date Created : 04.01.2018

Date of Implementation: 04.01.2018

Review No. 02 / 10.01.2019

Designation: Executive Director

Approved By : Name : Dr. Shaila Suhas Kumbhar

POLICY AND PROCEDURES ON

(MOM : 01) POLICY AND PROCEDURES ON PHARMACY SERVICES & USAGE OF

Pharmacy and other Patient Care Areas

Medical Director, Doctors, Departmental Heads, Purchase Officer, Stores Officer

NABH : National Accreditation Board for Hospitals and Healthcare providers

1.1 POLICY ON PHARMACY STORAGE & USAGE OF MEDICATION

a) Yash Hospital pharmacy is registered under Drug Controller of India.

POLICY AND PROCEDURES ON

c) 24 hours pharmacy services is provided in Yash hospital. Hospital drug formulary is

d) Request for purchase of a non-formulary medicine can be requested using the

i) Selection of implantable prosthesis shall be based on scientific criteria and

j) All implants / implantable prosthesis shall be procured through a defined process,

1.5 MEDICATION PROCUREMENT:

a) Pharmacy may substitute generic equivalents of brand name drugs ordered.

POLICY AND PROCEDURES ON

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

1.6 MEDICATION STORAGE:

a) Pharmacy Services shall be responsible for accurate drug storage, distribution,

d) The refrigerators / freezers holding perishable medicines shall be in good working

g) Look alike or sound alike medicines shall be stored separately.

1.7 MEDICATION FORMULARY:

POLICY AND PROCEDURES ON

1.8 PROCUREMENT & USAGE OF IMPLANTABLE PROSTHESIS:

h) Every patient undergoing surgery for installation of an implant or device shall be

POLICY AND PROCEDURES ON

(MOM : 02) POLICY AND PROCEDURES ON STORAGE OF MEDICATION

To provide guidelines on storage of medicines.

7.1. Medical Director

POLICY AND PROCEDURES ON

7.7. Medications shall be protected from loss and theft.

7.9. Emergency medicines should be available all time.

7.10. Emergency medications shall be replenished in a timely manner when used.

7.12. The medicine shall be stored by molecular name in an alphabetical order.

7.13. Organization shall conduct audits at regular intervals every quarter.

7.1. Storage Of Medication: Medications are stored in the pharmacy/floor according to

POLICY AND PROCEDURES ON

7.10. LIGHT SENSITIVE MEDICATIONS: Medications that are considered light-

POLICY AND PROCEDURES ON

Ward in-charge Nursing staff. Floor Stock Medications will be maintained in

7.14. OBTAIN MEDICATION WHEN THE PHARMACY IS CLOSED: In case if the

POLICY AND PROCEDURES ON

(MOM – 03) POLICY AND PROCEDURES ON STORAGE OF MEDICATION

1.0 POLICY ON PRESCRIPTION OF MEDICATION

2.1 RATIONAL PRESCRIPTION OF MEDICATION:

a) None other than a qualified doctor is permitted to prescribe medicines to a patient

POLICY AND PROCEDURES ON

2.2 REQUIREMENTS OF PRESCRIPTION:

a) Each prescription or continuation prescriptions should be signed with date / time by

b) The following details shall be contained in all prescriptions, minimum:

8.6.b.1 Patient’s MRD number;

c) The OP visiting patients shall be prescribed medicines in the particular OP