mmu chapter - jcia 2013

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All MMU chapter standards with all evidenced required to be met.

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  • 1.Medication Management And Use April, 2013Prepared by: Mr. Mouad Hourani. Bsc, RN, MPh Quality Improvement and Patient Safety Officer

2. Topics 1. 2. 3. 4. 5. 6. 7. 8. 9.Introduction. Medication Management and Use Cycle. Organization and Management. Selection and Procurement. Storage. Ordering and Transcribing. Preparing and Dispensing Administration. Monitoring. 3. Medication management encompasses the system and processes an organization uses to provide pharmacotherapies to its patients. It is usually a multidisciplinary, coordinated effort of staff of a health care organization, applying the principles of effective process design, implementation, and improvement to the selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication therapies. 4. ProcuringStoringMonitoringOrdering/DocumentingPrescribingAdministeringTranscribingDispensingDistributingPreparing 5. Standard MMU.1 Medication use in the organization complies with applicable laws and regulations and is organized to meet patient needs.Standard MMU.1.1 An appropriately licensed pharmacist, technician, or other trained professional supervises the pharmacy or pharmaceutical service. 6. RequirementsMMU.1 - ME 1 There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization.Medication Management Plan. P & T committee. 7. MMU.1 - ME 2RequirementsAll settings, services, and individuals who manage medication processes are included in the organizational structure.Pharmacy Scope of services Pharmacy Organizational structure. TOR of P&T committee 8. RequirementsMMU.1 - ME 3 Policies guide all phases of medication management and medication use in the organization.All medication use cycle related policies. 9. RequirementsMMU.1 - ME 4 There is at least one documented review of the medication management system within the previous 12 months.Review of Medication Management Plan through P&T meeting minutes. 10. RequirementsMMU.1 - ME 5 The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations.Laws and regulations related to medication management and use such as MOH, Narcotics Law. 11. RequirementsMMU.1 - ME 6 Appropriate sources of drug information are readily available to those involved in medication use.Drug formulary available electronically or printed out and accessed to all healthcare providers. 12. RequirementsMMU.1.1 - ME 1 An appropriately licensed, certified, and trained individual supervises all activities. (Also see GLD.5, ME 1)Certifications and job description of the pharmacy director (employee file). 13. RequirementsMMU.1.1 - ME 2 The individual provides supervision for the processes described in MMU.2 through MMU.5Director job description. Pharmacy organizational structure. 14. MMU.2 An appropriate selection of medications for prescribing or ordering is stocked or readily available.MMU.2.1 There is a method for overseeing the organizations medication list and medication use.MMU.2.2 The organization can readily obtain medications not stocked or normally available to the organization or for times when the pharmacy is closed. 15. RequirementsMMU.2 - ME 1 There is a list of medications stocked in the organization or readily available from outside sources. Medication Formulary developed contains quantities and location within organization. Medication list developed contains quantities and location outside organization. Note: P&T committee minutes shows review of medications required as per scope of service. 16. RequirementsMMU.2 - ME 2 A collaborative process was used to develop the list (unless determined by regulation or an authority outside the organization). Pharmacy therapeutic committee TOR . Meeting minutes of approving the Drug formulary. Note: P&T committee will chose from MOH formulary the medication used as per hospital scope of service. 17. RequirementsMMU.2 - ME 3 There is a process established for when medications are not available that includes a notification to prescribers and suggested substitutions. Drug Formulary policy (for not available medications). Medication Ordering, Prescribing, and Dispensing Policy. (for Suggested substitutions). Medication and Medical Supplies Procurement Policy (for not available medications). 18. RequirementsMMU.2.1 - ME 1 There is a method for overseeing medication use in the organization.P&T committee TOR that includes overseeing the medication in the organization. 19. RequirementsMMU.2.1 - ME 2 Medications are protected from loss or theft throughout the organization.Policy of access to medication. Note: surveyor will observe the medication area if secured or not. 20. RequirementsMMU.2.1 - ME 3 Health care practitioners involved in ordering, dispensing, administering, and patient-monitoring processes are involved in evaluating and maintaining the medication list.Pharmacy therapeutic committee TOR (members are multidisciplinary). 21. RequirementsMMU.2.1 ME 4 Decisions to add or to remove medications from the list are guided by criteria.Drug Formulary policy. P&T committee TOR. 22. RequirementsMMU.2.1 ME 5 When medications are newly added to the list, there is a process or mechanism to monitor how the drug is used and any unanticipated adverse events.Newly added medication policy. Form of monitoring such medications. 23. RequirementsMMU.2.1 ME 6 The list is reviewed at least annually based on safety and efficacy information.Drug Formulary policy. Meeting minutes of P&T committee. 24. RequirementsMMU.2.2 ME 1 There is a process to approve and to procure required medications not stocked or normally available to the organization. (Also see GLD.3.2.1, ME 1).Policy of Medication and Medical Supplies Procurement. 25. RequirementsMMU.2.2 ME 2 There is a process to obtain medications at times the pharmacy is closed or medication supply locked. (Also see GLD.3.2.1, ME 2).Policy and procedure that explains the process of getting medications out of pharmacy duty or the medication supply locked. 26. RequirementsMMU.2.2 ME 3 Staff understands the processes.Education and training supported by attendance sheets. 27. MMU.3 Medications are properly and safely stored.MMU.3.1 Organization policy supports appropriate storage of medications and applicable nutrition products.MMU.3.2 Emergency medications are available, monitored, and safe when stored out of the pharmacy.MMU.3.3 The organization has a medication recall system. 28. RequirementsMMU.3 - ME 1 Medications are stored under conditions suitable for product stability.Medication Storage policy: Storage policy Drug Stability policy Multi-dose containers policy Assure using temp. and humidity monitoring storing. 29. RequirementsMMU.3 - ME 2 Controlled substances are accurately accounted for according to applicable laws and regulations.Narcotics policy based on laws and regulations. 30. RequirementsMMU.3 - ME 3 Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings.Medication dispensing policy (if ready to use). 31. RequirementsMMU.3 - ME 4 All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly. Pharmacy inspection form/checklist to monitor all medication storage areas. Storage policy Narcotic Policy Crash cart policy 32. RequirementsMMU.3 - ME 5 Organization policy defines how medications brought in by the patient are identified and stored.Medication brought from home policy. 33. RequirementsMMU.3.1 - ME 1 Organization policy defines how appropriate nutrition products are stored.Storage policy describes the way of storing nutrition products. 34. RequirementsMMU.3.1 - ME 2 Organization policy defines how radioactive, investigational, and similar medications are stored.Storage policy. 35. RequirementsMMU.3.1 - ME 3 Organization policy defines how sample medications are stored and controlled.Medication sample policy (in case of accepting to use). Preferable to prevent using such source of medication. 36. RequirementsMMU.3.1 - ME 4 All storage is according to organization policy.A periodical inspection report for all medication storage areas. 37. RequirementsMMU.3.2 - ME 1 Emergency medications are available in the units they will be needed or readily accessible within the organization to meet emergency needs. (Also see GLD.3.2.1, ME 1, and MMU.2.2, ME 1).Crash cart policy. 38. RequirementsMMU.3.2 - ME 2 Organization policy defines how emergency medications are stored, maintained, and protected from loss or theft.Crash cart policy. 39. RequirementsMMU.3.2 - ME 3 Emergency medications are monitored and replaced in a timely manner in accordance with organization policy after use or when expired or damaged.Crash cart policy. Monthly check list for crash cart. 40. RequirementsMMU.3.3 - ME 1 There is a medication recall system in place.Medication recall policy 41. RequirementsMMU.3.3 - ME 2 Policies and procedures address any use of medications known to be expired or outdated.Expired medication policy 42. RequirementsMMU.3.3 - ME 3 Policies and procedures address the destruction of medications known to be expired or outdated.Expired medication policy. (to assure from companies that they are destructing the expired medications) 43. RequirementsMMU.3.3 - ME 4 Policies and procedures are implemented.Return back logbook Observation 44. MMU.4 Prescribing, ordering, and transcribing are guided by policies and procedures.MMU.4.1 The organization defines the elements of a complete order or prescription and the types of orders that are acceptable for use.MMU.4.2 The organization identifies those qualified individuals permitted to prescribe or to order medications. Medications prescribed and administered MMU.4.3 are written in the patients record. 45. RequirementsMMU.4 - ME 1 Pol