10-implementing policies and procedures

8/11/2019 10-Implementing Policies and Procedures

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ImplementingPolicies and

Procedures



The basic purpose of establishingsystems, processes and guiding

them in policies and procedures isto implement them well .



Failing to implement, is wastingtime, money, effort and otherresources.



It is encouraged to have a minimumof 1 month between the date ofissue and the date of effect fororientation and in-service training

Policy Implementation



Implementation process involvesa period of three (3) months togive time for

distribution,

familiarization,actual practice andmonitoring




All the hospital staff shall sign in theAcknowledgement Sheet to signify that theyhave read and understood the Policies andProcedures (Hospital Wide, Departmental,Safety, Infection Control, etc.).

Original Copy filed as page 3 in the Manual keptin every department




Accrediting bodies require thatpolicies are:

Documented ApprovedCommunicated/educatedImplemented



Working /Departmental/

Multidisciplinary policiesProcesses

GuidelinesDaily work/ services



It costs organizations a lot of time,money and effort to work on

policies and procedures andestablish systems and processes.



Not living those policies may leadto unsafe patient care as well as

jeopardize the wellbeing of thestaff.



MPP- PH 034 (3)

“HANDLING OF

NA RCOTICS A ND

CONTROLLEDMEDICATIONS”



CBAHISTANDARDS



Why we have this

standard? The Ministry of Health (MOH) determines theprocedures for procurement, storage and

dispensing of narcotics and psychotropics. Suchrules must be respected. Provision of a uniformsteel cabinet with double locks in all patient careareas where small stock are allowed guaranteesstock safety. Stock access is limited to few people.On the other hand, main pharmacy supplies arekept behind steel door in a vault or large steel

cabinets. Access is limited to narcotic pharmacist-



PH.46 There is a system for auditingNarcotics and Psychotropic Drugs in

accordance with MOH regulations:PH.46.1 Auditing every shift in the pharmacy.PH.46.2 Auditing every shift in each nursing unit.

PH.46.3 Maintaining proper documentation ofdrug count and accountability in the pharmacy.PH.46.4 Maintaining proper documentation ofdrug count & accountability in each nursing unit.PH.46.5 Maintaining proper documentation ofempty containers of narcotics.PH.46.6 Evidence of proper disposal of unused

portion of an ampoule or a tablet.



Why we have thisstandard?

In order to ensure accuracy of count,a system for auditing between shiftsis required by the ministry of health.Maintenance of properdocumentation in presence of awitness minimizes the opportunityfor misuse or abuse of narcotics andpsychotropics.



PH.47 There is a system for PrescribingNarcotics and Psychotropic Drugs (ControlledDrugs) in accordance with MOH regulations

and includes but is not limited to:PH.47.1Using the MOH approved prescriptions.PH.47.2 Not allowing physicians to prescribe

controlled drugs for self or family members.PH.47.3 Allowing only clinical privilegedphysicians to prescribe.

PH.47.4 Allowing only psychiatrists andspecialists to prescribe psychotropics (exceptduring emergency).PH.47.5 Not allowing injectable narcotics andcontrolled dru s for out atients.



Why we have thisstandard?

Rules and regulation made by theministry of health (MOH) are to be

respected. Only approvedprescription format is used forprescribing. Prescribing privileges

and supply quantities are clearlystated in the MOH narcotic manual.Injectable drugs in this category arenot allowed for take home by thepatient.



To comply with Saudi Arab Government rules and regulations

governing importation and distribution of narcotic and controlleddrugs.To establish specific policy and guideline in order to maintainadequate control of the distribution, safeguarding andstorage of all narcotic and controlled drugs. To define each responsibility of the hospital personnelinvolve in prescribing, dispensing, administering, storing,and record-keeping of all narcotic and controlled drugs. To implement a system for auditing between shifts asrequired by the Ministry of Health that will ensure accuracyof count.Minimize the opportunity for misuse or abuse of narcoticsand psychotropics by maintaining proper documentation inpresence of a witness.

PURPOSE:



DEFINITION: Narcot ic Drug: A drug that producessleep or stupor, simultaneously relievingpain, such as opium, morphine, etc that

leads to increasing tolerance andphysiological dependence.Cont ro l led Drug: A controlled drug is

one whose use and distribution is tightlycontrolled because of its abuse potentialor risk. Prohibited drug is classified ascontrolled drug.



RESPONSIBILITY: The Narcotic In charge is solely responsiblefor the management of narcotic andcontrolled medications in pharmacy.

The Head Nurse is responsible for handlingthe above-mentioned drugs in the nursingcare areas.The Pharmacy staff, when narcotic-in-chargeis off-duty, is responsible for dispensing.The medical staff is responsible for adheringnarcotic and controlled policy in terms of

drug ordering.



POLICY: Only one drug is allowed per prescription.Prescription must be „Indelible‟. No verbal or telephone order is allowed in givingnarcotic medication. Narcotic & Prohibited drugs must be kept in a safe anddouble-locked cabinet. Only the Pharmacy Narcotic In charge or his designate

(on his absence) can supply, dispense drugs, and handlesafe keys. Strict compliance in handling regulated and prohibiteddrugs is mandatory in order to secure patients from itsabusive and addictive effect.



PROCEDURE:

Stocking/ storing • Pharmacy stock is under the control of

narcotic-in-charge. Stocks must be insecured custody and properly storedaccording to manufacturer‟s storagerecommendations.

Ward stock is under the safeguard of the headnurse or charge nurse on her absence. Wardshall carry only limited stocking, according totheir needs.



Labeling and monitoring expiring drugs • Complete drug name and its strength must be readable.• It shall carry its expiration date both for prepared or ready to use

drug.• Nearly expired drug, at least 2 months before its due date must

be notified to the Pharmacy Director particularly if the presentamount may not be consumed by the hospital from the estimatedconsumption. The Pharmacy Director is responsible for informingthe Central Medical Store for the management of expiring drug.

• Dispensing and supplying must conform to the pharmaceutical

practice of “Early Expirations” ; First-in, First-out and whennecessary, a later expiration date batch in the wards should bereplaced with batch earlier to expire by the narcotic-in-charge.

• Destruction of the expired drug shall be done only after approvalfrom the Central Medical Store. Proof of approval must be kept

and registration adjustment must be done correctly.



Dispensing and prescription guidelines • Only the approved prescription and drug name

must be used.• Only one drug per prescription is allowed.• Only oral preparations are dispensed to the

outpatients. Injection is strictly for inpatients only.• The rules and regulations for prescription

dispensing in the hospital must be adhered to:• Prescription without patient‟s complete data and

diagnosis shall not be served.



The controlled drugs in the hospital areclassified according to theprescription format as follows:

• Prohibited Drugs : The prohibited drugs areprescribed in the approved Prohibited Prescriptionwhich contains five sections.

• The first section contains the patient data to befilled by the nurse.

• The doctor shall fill the second and third sections.• The fourth section is for the dispensing pharmacist

and/or the patient or his relative.• The prescription must be written with blue pen, legible

and any cancellation invalidates it.



For In-Patients : Drugs for the in-patients aredirectly under the supervision of the Narcotic incharge. Borrower slip may be issued for inter-

departmental transfer of any scheduled drugs.This must be endorsed by the Head Nurse. Thedrug concerned must be replaced soon and theborrower slip cancelled thereafter. Only clinicalprivileged physicians are allowed to prescribeNarcotic and Psychotropic (Controlled) Drugs.



For Out-Patients: Syrup(Phenobarbitone): may be prescribed forup to 15 days maximum per consultationas stated on its stability. Tablets and oraldrops: May be prescribed for up to onemonth. Up to 7 days medication may be

issued to patients attending the ER whennecessary.



• The Normal Prescription Drugs • These drugs are prescribed using the normal prescription written with full

patient data.• They are either classified as Psychotropic or Controlled drugs.

• The Psychotropic drugs• The Psychotropic drugs belong to the same schedule as the

prohibited and are subject to the same rules and regulations.• The prescription of these drugs is limited to the psychiatrists only.• Specialists in other medical fields should not prescribe them

except for some specified diagnosis related to their field ofspecialty or in emergency.

• Cases of depression and anxiety are to be referred to thepsychiatric hospital.

• No doctor shall prescribe psychotropic drug for himself/familymembers.

• Controlled Drugs • Injectable narcotic/controlled drugs should not be dispensed for

outpatient.



Record Keeping

• Proper daily documentation shall be carried out in line with thespecifications in the MOH and KSA drug schedule.

• The established routine in the hospital regarding the individual drugcontrol and statistics must be adhered to:

• Recording prescription daily in the register for daily supply.• Providing quarterly statistics return to the MOH for the respective

drugs.• Monthly statistics return for the single normal prescription items as

required by the MOH• Proper documentation of empty containers, unused portion of an

ampoule or tablet of a narcotic /controlled drug.• Proper monthly filing of the prescriptions in a safe place. Narcotic

prescriptions and register to be kept for 10 years, controlledprescriptions for 2 years and register shall be kept safe for a periodof 5 years.



Narcotic and Controlled Drugs In The Wards:

• Few amounts of controlled drugs are kept in each ward as perconsumption pattern. They are to be kept in the steel vault provided.

• The head nurse is responsible for the safety and properdocumentation for the drugs under her care.

• Prescriptions for narcotic and controlled drugs are made by theattending doctor.

• The head nurse or shift-in-charge supplies the drug to the nurseassigned to the particular patient as per the doctor‟s order. Theappropriate documentation should be entered immediately in theregister.

• Prescription shall be replaced via the head nurse or her designatewho shall verify the physician‟s order and consumptionendorsement in the ward before bringing the prescription to thepharmacy. The replaced quantity shall be returned to the ward bythe head nurse or her designate after filling from the pharmacy.

R l & R g l ti F D t &



Rules & Regulations For Doctors &Nurses regarding Narcotic &Prohibited Drugs

• Ward stock should be under the responsibility of the HeadNurse:

• Label : Expiration dates must be present for all drugs. Nearlyexpiring drugs, specifically two months before its expiry datemust be notified to narcotic-in-charge.

• Narcotic Checklist : After endorsement it must be signed together byendorser and receiver. If there is any discrepancy, it must be written inthe remarks column and the narcotic in- charge or the nursing supervisorshould be informed.

• Narcotic Register : Amount of drugs supplied, borrowed, given and

discarded must be written clearly in the register. No liquid eraser isallowed. Discarded portion must be written in red ink.

• Safe Keys : Safe keys must be endorsed to the person receiving theendorsement and should be always available in the ward. Only the Headnurse or the shift- in – charge or her designate can handle the keys in herabsence.



Prescriptions:• All prescriptions must be completely and properly filled up

and signed by the doctor.• Each prescription must be written in un-erasable ink.

• Only one item is allowed per prescription.• The prescribed amount and strength should be written

in the prescription.• Any alterations of the patient‟s name, drug name,

dosage or duration invalidate the prescription. Thisshould be cancelled and another prescription issued.• Any alterations of the time, date, age, nationality, chart

no and diagnosis should be countersigned by theprescribing doctor.



The prescription is divided into 5 sections.Patient‟s data to be written by the nurse and

the diagnosis by the doctor. Drug name,dose, frequency route of administration tobe written by the doctor. For take homemedications only relatives of patient areallowed to receive the prescribed medicineswith ID. After giving the medication to thenurse, the head nurse and the doctor must

write their names with signatures

Only one item is allowed per



Only one item is allowed perprescription.

• In Patients : The prescription for tablet and injection shallbe for 3 days only (regular dose).For stat dose one dayonly. Syrup phenobarbitone can be prescribed up to 15days.

• Out Patients : Tablets can be prescribed up to 30 days only. InER prescriptions 7 days medication can be prescribed. It mustbe written in the patient‟s file. No injectable drug will be issuedto out-patients. Syrups-15days maximum per consultation.Prescription cannot be filled in after 7 days.

• Controlled Drugs : Should be prescribed in double normalprescription. Date, time started, due and total should be writtenin the Prescription.



Administration of Drugs: Prior to administration, prescription,medication sheet and the order in physician‟s notes mustbe completed by prescribing doctor.

• Narcotic Drugs • The nurse should administer the drug in the presence of

the prescribing doctor and under his/her supervision,except for pre-medication.

• The amount of drug left over from the prescribed amount will bediscarded immediately under the supervision of the prescribingdoctor who will sign with the administering nurse.

• In pre-medication the drug should be given under thesupervision of head nurse and another nurse in the ward. Theyshould sign together for the destruction of the remainingquantity of drug, if the whole ampoule was not used.

• Narcotic drugs are not dispensed to outpatients.• Empty ampoules should be kept for replacement.



Prohibited Drugs :Date ordered, frequency, how manydays it will be given (max 3) should bewritten by the doctor on the medicationsheet. Injectable medication will remainup to 8 hrs. Any remaining amount canbe shared with other patients within the

ward.



• Supplied Form Of Prohibited & ControlledDrugs

• The nurse who has started the firstdose should write the date and timestarted, the amount given and signsthereafter. And likewise for the last

dose, but the total medicationconsumed must be included.• Shared medication to other patients

within the ward must also be writtenclearly.



• Borrower‟s slip: Used in borrowing prescribedmedications not available within the ward.

• It must be signed by the head nurse during duty hrs or by

the charge nurse and on following morning it must becountersigned by the head nurse.

• Broken Ampoule: Immediately inform the narcotic in-charge (during duty hrs) and nursing supervisor. Itshould be left untouched until the arrival of thenarcotic- in-charge or the nursing supervisor towitness the incident. It should be witnessed by theprescribing doctor. Incident report to be written atonce to be signed by the witnesses.



• Missing Ampoule: The narcotic-in-charge and thehead nurse should be informed immediately. Theincoming nurse who will receive endorsement should

write in the Narcotic Checklist the missing ampoule.Refused Medication Or Opened Ampoule Not Used: Informthe head nurse. If off-duty inform the nursing supervisor.Inform all the wards regarding the unused ampoule and

keep the medicine for 8 hrs. If not used within 8 hrs, thedoctor on duty or the prescribing doctor should write thereason in the patient‟s file. Prescription must be made andmedicine should be discarded (narcotic medicine can't bekept for 8 hrs).



FORMS & EQUIPMENT: Prescription Form for Narcotic Drugs

Prescription Form for Controlled Drugs Quarterly Report of Narcotic Drug Quarterly Report of Prohibited Drug Medication Chart for Given & Discarded Amount of Narcotic Drug Medication Chart for Given & Discarded Amount of Prohibited &Controlled Drug Borrower's Slip Ward Round for Narcotic Drug Inspection Form Special Anaesthetic Request FormNarcotic Prescription Log-in Sheet

Prohibited Prescription Log-in SheetNarcotic Checklist FormRegister Form for Administered Narcotic & Controlled DrugRegister Form for Used Prohibited & Controlled DrugRegister Form for Daily Supply of Narcotic Drug

Narcotic Empty Ampoule Destructed Form

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