Management of Medication "MOM" NABH-6-STD-Jan-2025.pdf

The Institute of Medicine reports 44,000 to 98,000 people die in hospitals annually as a result of medical errors that could have been prevented (Kohn, Corrigan, & Donaldson, 2000). Medication errors accounted for 7,391 deaths in
1993, compared to 2,876 deaths in 1983 (Kohn et al., 2000). These medication errors and the adverse reactions connected with them result in increased length of stay,
increased cost, patient disability, and death.

1. Quality Improvement Programme
to Creating Quality Culture in India
Dr J L Meena
Govt of India

2. Quality Improvement Programme
to Creating Quality Culture in India
Quality is a Team
Work, Never Achieve
by a Single Person
Quality Never
Improve without
Truth
Jo Aap Ko
Chahiye, Bo
Dusron Ko Do
Quality Coming
from your Heart
Self Assessment
is the Best
Assessment for
Quality
Dr. J. L. Meena
Total 639 Objective Elements
❖100 are in core category which will be
mandatorily assessed during each
assessment,
❖457 are in commitment category which
will be assessed during final
assessment,
❖60 are in achievement category which
will be assessed during surveillance
assessment
❖17 are in excellence category which will
be assessed during re- accreditation.
This will help the healthcare organisation
in step wise progression to mature quality
system covering the full accreditation cycle.

3. Introduction
Dr. J. L. Meena
The standards provide framework for quality
assurance and quality improvement for hospitals.
The standards focus on patient safety and quality of
care. The standards call for continuous monitoring
of sentinel events and comprehensive corrective
action plan leading to building of quality culture at
all levels and across all the functions.

4. Outline of NABH Standards
Access,
Assessment and
Continuity of
Care (AAC).
Care of Patients
(COP).
Management of
Medication
(MOM).
Patient Rights
and Education
(PRE).
Infection
Prevention &
Control (IPC).
Patient Safety
& Quality
Improvement
(PSQ).
Responsibility of
Management
(ROM).
Facility
Management &
Safety (FMS).
Human
Resource
Management
(HRM).
Information
Management
System (IMS).Patient
Centered
Standards
Organisation
Centered
Standards
Dr. J. L. Meena

5. Chapters, Standards & Objective Elements
Chapters Standards
Objective
Elements
Core Commitment Achievement Excellence
AAC 13 87 6 68 9 4
COP 20 135 13 107 12 4
MOM 11 68 13 48 6 1
PRE 8 52 12 32 7 1
IPC 8 49 13 33 3 0
PSQ 7 46 8 28 7 3
ROM 6 37 4 23 8 2
FMS 7 43 11 29 2 1
HRM 13 76 16 56 4 0
IMS 7 45 9 33 2 1
Total 100 639 105 457 60 17

6. Intent of the chapter:
Management of Medication (MOM)
➢The organisation has a safe and organised medication process. The availability, safe storage, prescription, dispensing
and administration of medications is governed by written guidance.Theorganisationdesignatesamedicalsafetyofficer.
➢The organisationdevelops,implementsandupdatesthehospitalformulary.Thepharmacy shall have oversight
of all medications stocked out of the pharmacy. The pharmacy shall ensure correct storage (as regards to temperature,
light; high-risk medications including look-alike, sound- alike, etc.), expiry dates and maintenance of documentation.
➢The availability of emergency medication is stressed upon. The organisation should have a mechanism to ensure that
the emergency medications are standardised throughout the organisation, readily available and replenished promptly.
There should be a monitoring mechanism to ensure that the required medications are always stocked and well within
expiry dates.
➢Every high-risk medication order should be verified by an appropriate person to ensure accuracy of the dose, frequency
and route of administration. Safety is paramount when using narcotics, chemotherapeutic agents and radioactive agents
andradiopharmaceuticals.Reconciliationofmedicationsoccursattransitionpointsofpatientcareaspartofpatientsafety.
➢The medicationmanagementprocessalso includes monitoring of patients after administration and procedures for
reporting and analysing near-misses, medication errors and adverse drug reactions.
➢Medications also include blood, implants and devices. Medical supplies and consumables are available for use.
6
Dr. J. L. MeenaCRECommitment Achievement Excellence

7. A Case Study
TheInstituteofMedicinereports44,000to98,000people
dieinhospitalsannuallyasaresultofmedicalerrorsthat
couldhavebeenprevented(Kohn,Corrigan,&Donaldson,
2000).Medicationerrorsaccountedfor7,391deathsin
1993,comparedto2,876deathsin1983(Kohnetal.,2000).
Thesemedicationerrorsandtheadversereactions
connectedwiththemresultinincreasedlengthofstay,
increasedcost,patientdisability,anddeath.
C RECommitment Achievement Excellence Dr. J. L. Meena

8. A Case Study
Themedicationdeliveryprocessiscomplexandinvolves
hand-offsbetweenmanyindividualsanddepartments.Errors
mayoccuratanyoftheprocesssteps:-prescription,
transcription,dispensing,oradministration.Mosterror-
reportingsystemsrelyonvoluntaryself-reportingandare
imbeddedintowhatremainlargelypunitivemanagement
systems.Nurseswidelyreportreluctancetodisclose
medicationerrors,particularlyifanerrordoesnotresultin
patientharm..
C RECommitment Achievement Excellence Dr. J. L. Meena

9. Common Cause of Medical
Mistakes
➢Ignorance
➢Inexperience
➢Faulty judgment
➢Hesitation
➢Fatigue
C RECommitment Achievement Excellence Dr. J. L. Meena

10. ➢Job overload
➢Breaks in concentration
➢Faulty communication
➢Failure to monitor closely
➢System flaws
C RECommitment Achievement Excellence Dr. J. L. Meena
Common Cause of Medical
Mistakes

11. Why doctors err..
1.PhysicianStressors:-
➢Feelinghurriedordistracted,usuallybecauseotherpatientswere
waitingtobeseenorbecausethetimeofthevisitwasstressful
(e.g.,night,weekend,off-dutyhours,quittingtime.)
➢Feelingfatigued.
➢Beingmisledbyadviceoranticipatedadvicefromother
physicians.
➢Avoidingamedicalinterventionbecauseofitscost.
C RECommitment Achievement Excellence Dr. J. L. Meena

12. 2.Process-of-CareFactors:-
➢Beingtoofocusedononediagnosisortreatmentplan.
➢Notbeingaggressiveenoughindiagnosingortreating(e.g.,didn't
diagnosecancerbecauseofthepatient'syoungage).
➢Lackinganadequatefollow-upplan.
➢Notaskingadvice.
C RECommitment Achievement Excellence Dr. J. L. Meena
Why doctors err..

13. 3.Patient-RelatedFactors
➢Beingmisledbyanormalornegativehistory,physical
examination,laboratoryresult,orimagingstudy,which
overshadowedothersignsthatthepatienthadasignificantillness.
➢Notrespondingwithaggressivetreatmentbecausethepatient
eitherunderreportedsymptomsorinsistedonaninappropriately
conservativetreatment.
➢Havinganattitudeofdislikeorunusualfondness
➢towardthepatientthathindersobjectivity.
C RECommitment Achievement Excellence Dr. J. L. Meena
Why doctors err..

14. 4.PhysicianCharacteristics
➢Lackingknowledgeaboutthemedicalaspectsofthecase
becauseofinexperience.
➢Havingtoomuchprideinhisorherownabilitieswhich
leadstoawrongdecision.
C RECommitment Achievement Excellence Dr. J. L. Meena
Why doctors err..

15. Simple Truths about errors in
medicine
Thereisawell-establishedbodyofresearchabouterrorsinmedicine,and
mostexpertsagreeonthefollowing:
1.Errorswillhappen.Sincenohumanisperfect,errorsareboundtohappen,and
thisincludesphysiciansandtheirstaffsworkinginthedeliveryofhealthcare
services.
2.Sinceerrorscanbeexpected,systemsmustbedesignedtopreventandabsorb
them.
3.Errorsarenotsynonymouswithnegligence.Medicine'sethosofinfallibilityleads,
wrongly,toaculturethatseesmistakesasanindividualproblemandremedies
themwithblameandpunishmentinsteadoflookingforrootcausesandfixing
problemsbyimprovingsystems.
4.Creatingaculturesupportiveoferrorsreportingisthestartingpointinreducing
futuremedicalerrors.
C RECommitment Achievement Excellence Dr. J. L. Meena

16. Type of Medical Mistakes
C RECommitment Achievement Excellence Dr. J. L. Meena

17. Different types of Adverse
Medication Events
1. Wrong drug
2. Wrong dose and/or frequency
3. Wrong form
4. Wrong route
5. Wrong rate
6. Wrong time
7. Wrong preparation
8. Wrong patient
C RECommitment Achievement Excellence Dr. J. L. Meena

18. 9. Wrong documentation
10. Omitted drug or dose
11. Allergy information missing
12. Inadequate or inappropriate
monitoring
13. Administered when c e a s e d or
w it h h e l d
14. Administered but not signed
15. Extra dose given on over dose.
C RECommitment Achievement Excellence Dr. J. L. Meena
Different types of Adverse
Medication Events

19. Summary of Standards
Management of Medication (MOM)
MOM.1. Pharmacy services and usage of medication is done safely.
MOM.2. The organisation develops, updates and implements a hospital formulary.
MOM.3. Medications are stored appropriately and are available where required.
MOM.4. Medications are prescribed safely and rationally.
MOM.5. Medication orders are written in a uniform manner.
MOM.6. Medications are dispensed in a safe manner.
MOM.7. Medications are administered safely.
MOM.8. Patients are monitored after medication administration.
MOM.9.
Narcotic drugs and psychotropic substances, chemotherapeutic agents and radio-
pharmaceuticals are used safely.
MOM.10. Implantable prosthesis and medical devices are used in accordance with laid down criteria.
MOM.11. Medical supplies and consumables are stored appropriately and are available where required.
19
Dr. J. L. MeenaCRECommitment Achievement Excellence

20. Summary of Objective Elements
ManagementofMedication(MOM)
Objective
Elements
MOM 1 MOM 2 MOM 3 MOM 4 MOM 5 MOM 6 MOM 7 MOM 8 MOM 9 MOM 10 MOM 11
a Commitment CORE CORE CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment
b Commitment Commitment Commitment CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment
c Achievement Commitment CORE Commitment Commitment Commitment Commitment CORE Commitment Commitment Commitment
d Commitment
Achievement
Achievement Excellence Commitment CORE CORE Commitment Commitment Commitment Commitment
e
Commitment
Commitment CORE CORE CORE Commitment Commitment Commitment Achievement Commitment
f Commitment Commitment CORE Commitment Commitment Commitment
g CORE Achievement Commitment
h Achievement CORE
i Commitment
j Commitment
k Commitment
Summary Standards -11 OE 68 CORE 13 Commitment 48 Achievement 6 Excellence 1
Dr. J. L. MeenaC RECommitment Achievement Excellence

21. MOM 1 - Pharmacy services and usage of
medication is done safely.
Objective Elements
a)Pharmacy services and medication usage are implemented following written
guidance. *
b)A multidisciplinary committee guides the formulation and implementation of
pharmacy services and medication management.
c)There is a mechanism in place to facilitate the multidisciplinary committee to
monitor literature reviews and best practice information on medication
management and use the information to update medication management
processes.
d)There is a procedure to obtain medication when the pharmacy is closedor in case
of stock outs. *
e)The organisation has a mechanism to inform relevant staff of key changes in
pharmacy services and medication usage to ensure uninterrupted and safe care.
21
Dr. J. L. MeenaCRECommitment Achievement Excellence

22. MOM 2 - The organisation develops, updates
and implements a hospital formulary.
Objective Elements
a)A list of medications appropriate for the patients and as per the scope of the
organisation's clinical services is developed collaboratively by the multidisciplinary
committee.
b)The list is reviewed and updated collaboratively by the multidisciplinary committee
at least annually.
c)The current formulary is available for clinicians to refer to.
d)The clinicians adhere to the current formulary.
e)The organisation adheres to the procedure for the acquisition of formulary
medications. *
f)The organisation adheres to the procedure to obtain medications not listed in the
formulary. *
22
Dr. J. L. MeenaCRECommitment Achievement Excellence

23. MOM 3 - Medications are stored appropriately
and are available where required.
Objective Elements
a)Medications are stored in a clean, safe and secure environment; and incorporating the
manufacturer's recommendation(s).
b)Sound inventory control practices guide storage of the medications throughout the
organisation.
c)The organisation defines a list of high-risk medication(s). *
d)High-risk medications are stored in areas of the organisation where it is clinically necessary.
e)High-risk medications including look-alike, sound-alike medications and different
concentrations of the same medication are stored physically apart from each other. *
f)The list of emergency medications is defined and is stored uniformly. *
g)Emergency medications are available all the time and are replenished promptly when used.
23
Dr. J. L. MeenaCRECommitment Achievement Excellence

24. Temperature monitoring of the drug
storage area
Infact,mostprescriptionandnearlyalloverthecounterdrugsare
requiredtobekeptatcontrolledroomtemperature.TheUnited
StatesPharmacopeia(USP)hasdefinedControlledRoom
Temperature(CRT)as:"Atemperaturemaintainedthermostatically
thatencompassestheusualandcustomaryworkingenvironmentof
20to25°C(68to77°F);andthatallowsforexcursionsbetween15
and30°C(59and86°F)thatareexperiencedinpharmacies,
hospitals,andwarehouses.”youneedtobeawarethatstorageat
hightemperaturescanquicklydegradethepotencyandstabilityof
drug.
C RECommitment Achievement Excellence Dr. J. L. Meena

25. Temperature monitoring of the
drug storage area
Temperatures,otherthanwhatthemanufacturerrecommends,can
degradethedrugs,makingthemlesseffectiveandputtingpatientsin
potentialdanger.AbbottLabs,Synthroid'smanufacturer,recommends
thatpatientsreplacetheirthyroidmedsifthey'vebeenstoredat
temperaturesabove86°Fforanylengthoftime.
Formoterol,adrugusedforasthmaandCOPDisexposedtohighheatfor
aprolongedperiodoftime,thepowderturnsclumpyandbrown,
deliveringlessthanhalfofitsintendeddosage.
Catechinsprovideantioxidantbenefitsandarefoundinvarious
supplements.Thosesupplementsstoredathightemperatures,losethe
mostcatechins.
Dr. J. L. MeenaC RECommitment Achievement Excellence

26. ABC Analysis
Theannualexpenditureofindividualitemswasarrangedin
descendingorder.Thecumulativecostofalltheitemswas
calculated.Thecumulativepercentageofexpenditureandthe
cumulativepercentageofnumberofitemswerecalculated.
Thislistwasthensubdividedintothreecategories:A,BandC,
basedonthecumulativecostpercentageof70%,20%and
10%,respectively.
Dr. J. L. MeenaC RECommitment Achievement Excellence

27. 'A'items-20%oftheitemsaccountsfor70%ofthe
annualconsumptionvalueoftheitems.
'B'items-30%oftheitemsaccountsfor20%ofthe
annualconsumptionvalueoftheitems.
'C'items-50%oftheitemsaccountsfor10%ofthe
annualconsumptionvalueoftheitems
Dr. J. L. MeenaC RECommitment Achievement Excellence
ABC Analysis

28. Distribution of ABC Class
Dr. J. L. MeenaC RECommitment Achievement Excellence

29. Application of Weighed Purchasing
condition
Dr. J. L. MeenaC RECommitment Achievement Excellence

30. VED Analysis
TheVEDcriticalityanalysisofallthelisteditemswasperformedbyclassifying
theitemsintovital(V),essential(E)anddesirable(D)categories.Theitems
criticallyneededforthesurvivalofthepatientsandthosethatmustbe
availableatalltimeswereincludedintheVcategory.Theitemswithalower
criticalityneedandthosethatmaybeavailableinthehospitalwereincluded
intheEgroup.Theremainingitemswithlowestcriticality,theshortageof
whichwouldnotbedetrimentaltothehealthofthepatients,wereincluded
intheDgroup.TheVEDstatusofeachitemwasdiscussedwithjustification
byagroupcomprisingofphysician,surgeon,pediatricianandpharmacist.
Dr. J. L. MeenaC RECommitment Achievement Excellence

31. ABC –VED Matrix Analysis
Dr. J. L. MeenaC RECommitment Achievement Excellence

32. Dr. J. L. MeenaC RECommitment Achievement Excellence
ABC –VED Matrix Analysis

33. Comparison of ABC, VED and ABC-VED
matrix analysis of different studies in
India
Dr. J. L. MeenaC RECommitment Achievement Excellence

34. How to do FSN / FNS Analysis
Dr. J. L. MeenaC RECommitment Achievement Excellence

35. There following steps in doing
the FSN analysis
➢Calculationofaveragestayandtheconsumptionrateof
thematerialinStorehouse:-
➢FSNClassificationofmaterialsbasedonaveragestayinthe
inventory.
➢FSNClassificationofthematerialbasedonconsumption
rate.
➢FinallyclassifyingbasedonaboveFSNanalysis.
Dr. J. L. MeenaC RECommitment Achievement Excellence

36. Process of FSN analysis
Dr. J. L. MeenaC RECommitment Achievement Excellence

37. Process of FSN analysis
Averagestayofthematerial=CumulativeNoofInventory
HoldingDays/Totalquantityreceived+OpeningBalance)
=1161/115=10.09Days
ConsumptionRate=TotalIssueQty/TotalPeriodDuration
=46/15=3.06Nos/Day
Dr. J. L. MeenaC RECommitment Achievement Excellence

38. Now list down the material with
average stay and consumption rate
Dr. J. L. MeenaC RECommitment Achievement Excellence

39. Now Carry out the FSN analysis on
the basis of Average Stay only
Dr. J. L. MeenaC RECommitment Achievement Excellence

40. Now Carry out the FSN analysis on
the basis of consumption rate
Dr. J. L. MeenaC RECommitment Achievement Excellence

41. Now carry out final classification by
combining both as under
Dr. J. L. MeenaC RECommitment Achievement Excellence

42. First -In / First -Out Procedure
(FIFO)
Amethodofinventorymanagementinwhichthefirst
productsreceivedarethefirstproductsissued.This
methodsgenerallyminimizesthechanceofdrug
expiration.
Dr. J. L. MeenaC RECommitment Achievement Excellence

43. First Expiry / First Out Procedure
(FEFO)
Amethodofinventorymanagementinwhichproductswith
theearliestexpirydatearethefirstproductsissued,
regardlessoftheorderinwhichtheyarereceived.This
methodismoredemandingthanFIFO(seebelow)butshould
beusedforshort-datedproductssuchasvaccines.
Dr. J. L. MeenaC RECommitment Achievement Excellence

44. Look –Alike / Sound –Alike Drugs
for Surgical Facilities e.g.
Dr. J. L. MeenaC RECommitment Achievement Excellence

45. Dr. J. L. MeenaC RECommitment Achievement Excellence
Look –Alike / Sound –Alike Drugs
for Surgical Facilities e.g.

46. Dr. J. L. MeenaC RECommitment Achievement Excellence
Look –Alike / Sound –Alike Drugs
for Surgical Facilities e.g.

47. Dr. J. L. MeenaC RECommitment Achievement Excellence
Look –Alike / Sound –Alike Drugs
for Surgical Facilities e.g.

48. MOM 4 - Medications are prescribed safely and
rationally.
Objective Elements
a)Medication prescription is in consonance with good practices/guidelines for the rational
prescription of medications. *
b)The organisation adheres to the determined minimum requirements of a prescription. *
c)Drug allergies and previous adverse drug reactions are ascertained before prescribing.
d)The organisation has a mechanism to assist the clinician in prescribing appropriate
medication.
e)Reconciliationofmedicationsoccursattransitionpointsofpatientcare.
f)Verbalordersare iimplemented by ensuring safe medication management practices. *
g)Audit of medication orders/prescription is carried out to check for safe and rational
prescription of medications.
h)Corrective and/or preventive action(s) is taken based on the audit, where appropriate.
48
Dr. J. L. MeenaCRECommitment Achievement Excellence

49. Narrow Therapeutic Index
Drugswithnarrowtherapeuticindex(NTI-drugs)aredrugs
withsmalldifferencesbetweentherapeuticandtoxicdoses.
Thepatternofdrug-relatedproblems(DRPs)associatedwith
thesedrugshasnotbeenexplored.
Dr. J. L. MeenaC RECommitment Achievement Excellence

50. Dr. J. L. Meena
Narrow Therapeutic Index

51. MOM 5 - Medications orders are written in a
uniform manner.
Objective Elements
a)The organisation ensures that only authorised personnel write
orders. *
b)Medication orders are written in a uniform location in the medical
records, which also reflects the patient's name and unique
identification number.
c)Medication orders are legible, dated, timed and signed.
d)Medication orders contain the name of the medicine, route of
administration, strength to be administered and frequency/time of
administration.
51
Dr. J. L. MeenaCRECommitment Achievement Excellence

52. MOM 6 - Medications are dispensed in a safe
manner.
Objective Elements
a)Dispensing of medications is done safely. *
b)Medication recalls are handled effectively. *
c)Near-expiry medications are handled effectively. *
d)Dispensed medications are labelled. *
e)High-risk medication orders are verified before dispensing.
f)Return of medications to the pharmacy is addressed. *
52
Dr. J. L. MeenaCRECommitment Achievement Excellence

53. MOM 7 - Medications are administered safely.
Objective Elements
a)Medications are administered by those who are permitted by law to do so.
b)Prepared medication is labelled before preparation of a second drug.
c)The patient is identified before administration.
d)Medication is verified from the medication order and physically inspected before administration.
e)Strength is verified from the order before administration.
f)The route is verified from the order before administration.
g)Timing is verified from the order before administration.
h)Measures to avoid catheter and tubing mis-connections during medication administration are
implemented. *
i)Medication administration is documented.
j)Measures to govern patient's self-administration of medications are implemented. *
k)Measures to govern patient's medications brought from outside the organisation are
implemented. *
53
Dr. J. L. MeenaCRECommitment Achievement Excellence

54. MOM 8 - Patients are monitored after medication
administration.
Objective Elements
a)Patients are monitored after medication administration. *
b)Medications shall be changed based on the monitoringwhere appropriate.
c)The organisation captures near miss, medication error and adverse drug
reaction. *
d)Near miss, medication error and adverse drug reaction are reported within
a specified time frame. *
e)Near miss, medication error and adverse drug reaction are collected and
analysed.
f)Corrective and/or preventive action(s) are taken based on the analysis.
54
Dr. J. L. MeenaCRECommitment Achievement Excellence

55. Adversedrugeventsaredefined
Category Description Effect
Category A An error occurred that may have the capacity to cause error No Error
Category B An Error occurred but the error did not reach the patient Error, but No Harm
Category C An Error occurred that reached the patient but did not cause
patient harm
Error, but No Harm
Category D An error occurred that reached the patient and required monitoring
to confirm that it resulted in no harm to the patient and / or required intervention to preclude
harm
Error, but No Harm
Category E An Error occurred that may have contributed to or resulted in
temporary harm to the patient and required intervention
Error + Harm
Category F An error occurred that may have contributed to or resulted in
temporary harm to the patient and required initial or prolonged hospitalization
Error + Harm
Category G An error occurred that may have contributed to or resulted in
permanent patient harm
Error + Harm
Category H An error occurred that required intervention necessary to sustain
life
Error + Harm
Category I An error occurred that may have contributed to or resulted in the Error + Death

56. MOM 9 - Narcoticdrugsandpsychotropic
substances,chemotherapeuticagentsand
radio-pharmaceuticalsareusedsafely.
Objective Elements
a) Narcotic drugs and psychotropic substances, chemotherapeutic agents and
radioactive agents are used safely. *
56
Dr. J. L. MeenaCRECommitment Achievement Excellence
b) Narcotic drugs and psychotropic substances, chemotherapeuticagents and
radioactive agents are prescribed by appropriate caregivers.
c)Narcotic drugs and psychotropic substances, chemotherapeutic agents and
radioactive agents drugs are stored securely.
d)Chemotherapy and radio-pharmaceuticals shall be preparedproperlyandsafely
and administered by qualified personnel.
e)A proper record is kept of the usage, administration and disposal of narcotic drugs
and psychotropic substances, chemotherapeutic agents and radio-pharmaceuticals.

57. Drug Antidote Action Compresses
Nitrogen Mustard Sodium thiosulfate IV & SQ* Chemical neutralization Cold
Mitomycin
(topical Dimethyl Sulfoxide
[DMSO])
& oxygen radical scavenger Cold
Doxorubicin (topical DMSO)** & oxygen radical scavenger Cold
Daunorubicin (topical DMSO)** & oxygen radical scavenger Cold
Dactinomycin (topical DMSO)** & oxygen radical scavenger Cold
Vincristine No antidote available Drug absorption & dispersion Warm
Vinblastine No antidote available Drub absorption & dispersion Warm
Vindesine No antidote available Drub absorption & dispersion Warm
Dr. J. L. MeenaC RECommitment Achievement Excellence
Chemotherapy drugs are disposed off in
accordance with legal requirements

58. MOM 10 - Implantable prosthesis and medical
devices are used in accordance with laid down
criteria.
Objective Elements
a)Usage of the implantable prosthesis and medical devices is guided by scientific
criteria for each item and national/international recognised guidelines/ approvals
for such specific item(s).
b)The organisation implements a mechanism for the usage of the implantable
prosthesis and medical devices. *
c)Patient and his/her family are counselled for the usage of the implantable
prosthesis and medical device, including precautions if any.
d)The batch and the serial number of the implantable prosthesis and medical
devices are recorded in the patient's medical record, the master logbook and the
discharge summary.
e)Recall of implantable prosthesis and medical devices are handled effectively. *
58
Dr. J. L. MeenaCRECommitment Achievement Excellence

59. Selectionofimplantableprosthesisisbasedon
scientific criteriaandinternationallyrecognized
approvals
Steps Activity Responsibility
1 Signing of demand for the procurement of Implantable Prosthesis Head of user dept.
2 Estimation of the demand depending the current trend of patient Head of user dept.
3 Matching the selection criteria Head of user dept.
4 Formulation of policy and procedure guide for procurement and usage MOM Committee
PROCEDURE FOR USAGE OF IMPLATABLE PROSTHESIS:
1 Identification of the patient Nursing staff
2 Identification of the implant OT technician/ ICU Nurse
3 Sterilization of the prosthesis OT Technician
4 Use of the prosthesis in the patient Consultant In- Charge
5 Endorsing the and number in the OT well as patient sheet and the empty box to
the patient which contains the sticker of serial number and batch number.
OT Technician/ ICU Nurse
Dr. J. L. MeenaC RECommitment Achievement Excellence

60. MOM 11 - Medical supplies and consumables are
stored appropriately and are available where
required.
Objective Elements
a)The organisation adheres to the defined process for the acquisition of
medical supplies and consumables. *
b)Medical supplies and consumables are used in a safe manner, where
appropriate.
c)Medical supplies and consumables are stored in a clean, safe and secure
environment; and incorporating the manufacturer's recommendation(s).
d)Sound inventory control practices guide storage of medical supplies and
consumables
e)There is a mechanism in place to verify the condition of medical supplies and
consumables
60
Dr. J. L. MeenaCRECommitment Achievement Excellence

61. PHARMACOTHERAPEUTIC COMMITTEE
Scope of Work
➢Develop and issue Policy on formulary and
medication management
➢Supervise purchases and procurement
➢Supervise and management of pharmacy
➢Monitor and evaluate adverse drug
reactions
➢Manage the control of drugs
➢Supervise drug information service
Dr. J. L. MeenaC RECommitment Achievement Excellence

62. PHARMACOTHERAPEUTIC COMMITTEE
Function of the Committee
➢Thereisadocumentedpolicyandprocedureforpharmacyservicesandmedicationusage.
➢Policiesandproceduresguidetheorganizationofpharmacyservicesandusageof
medication.
➢Thepoliciesandproceduresshalladdresstheissuesrelatedtoprocurement,storage,
formulary,prescription,dispensing,administration,monitoringanduseofmedications.
➢Alistofmedicationappropriateforthepatient'sandtheorganization'sresourcesis
developed.
➢Policiesandproceduresguidetheprescriptionofmedications.
➢Policiesandproceduresguidethesafedispensingofmedications.
➢Policiesandproceduresguidetheuseofnarcoticdrugsandpsychotropicsubstances.
➢Policiesandproceduresgovernusageofradioactiveorinvestigationaldrugs.
➢Policiesandproceduresguidetheusageofchemotherapeuticagents.
➢Policiesandproceduresguidetheuseofimplantableprosthesis.
➢Policiesandproceduresguidetheshortageofmedication.
Dr. J. L. MeenaC RECommitment Achievement Excellence

63. PHARMACOTHERAPEUTIC COMMITTEE
How to Function
Name of Committee Members:-
CoH
Agenda identified by Committee:-
Date of Committee Meetings:-
Meeting Minutes of the Committee Meetings:-
Action Taken Report on the Agenda:-
Frequency of Meeting:-Monthly
Dr. J. L. MeenaC RECommitment Achievement Excellence

64. THANKS
“Want your support for Continues Improvement”