Medication Management (MM)
QUALITY ACCREDITATION DEPARTMENT
MEDICATION MANAGEMENT(MM)
MM.5 The hospital has a system for the safety of High Alert
Medication (HAM)
Intent:
High Alert Medications are drugs that bear a heightened risk of causing
patient harm when used in error.
Errors may not be common with these than with other medications, but
the consequences of errors my be devastating.
Several world wide organizations had identified a list of HAM such as
WHO & ISMP.
Hospitals shall have a plan for the safe use of these medications and
develop their own annually updated list of HAM with the related safety
strategies to minimize errors and harm from these medications and
hazardous pharmaceutical chemicals as much as possible
QUALITY ACCREDITATION DEPARTMENT
MM.5 :The hospital has a system for the
safety of High Alert Medication (HAM)
ME# MEASURABLE ELEMENTS ACTIVITY EVIDENCE
5.1 There is a written multidisciplinary plan for managing
high-alert medications and hazardous pharmaceutical Review policy :
chemicals. It includes identification, location, labeling,
storage, dispensing, and administration of high-alert Document Review High-alert Medications http:
medications. Restricted Medications.
5.2 The hospital identifies an annually updated list of high-
alert medications and hazardous pharmaceutical A list of HAM and Hazardous
chemicals based on its own data and national and Pharmaceutical chemicals
international recognized organizations (e.g., Institute of -medications included in the
Safe Medication Practice, World Health Organization). Hospital Formulary.
The list contains, but is not limited to, the following:
-including but not limited to the listed
5.2.1 Controlled and narcotics medications.
MM.5.2.1 - MM.5.2.9)
5.2.2 Neuromuscular blockers. Document Review
5.2.3 Chemotherapeutic agents
5.2.4 Concentrated electrolytes (e.g., hypertonic sodium
chloride, concentrated potassium salts).
5.2.5 Antithrombotic medications (e.g., heparin, warfarin).
5.2.6 Insulins.
5.2.7 Anesthetic medications (e.g., propofol, ketamine).
QUALITY ACCREDITATION DEPARTMENT
MM.6 The hospital has a system for the safety
of Look-alike and Sound-alike (LASA ) Medications.
ME# MEASURABLE ELEMENTS ACTIVITY EVIDENCE
5.2 Investigational (research) drugs, as Policy review:
applicable. High Alert Medication
Document Review HAM list attached to CPP -
5.29 Other medications as identified by the
hospital.
5.3 The hospital plan for managing high-alert Staff interview & observation:
medications and hazardous
pharmaceutical chemicals is KFMC Formulary and Lexi comp
implemented. This includes, but is not
limited to, the following: '[Link]
5.3.1 Improving access to information about ACY1/MedicationFormulary/SitePages
high-alert medications. /Guidlines%20and%[Link]
Observation
5.3.2 Limiting access to high-alert medications. Staff Interview -- evidence of implementation of
5.3.3 Using auxiliary labels or computerized high alert plan (MM.5.3.1 - MM.5.3.5)
alerts if available awareness of safety measures to
prevent errors
5.3.4 Standardizing the ordering, transcribing, -availability & access to drug
preparation, dispensing, administration, information: dosing , storage,
and monitoring of high-alert medications. precautions, adverse reactions
5.3.5 Employing independent double checks.
5.4 The hospital develops and implements Review policy
standard concentrations for all -Labelling of IV products-
Document Review
medications administered by intravenous -the hospital approved standard
Staff interview
infusion. concentrations(guidelines) for all
HAM administered Intra- Venous.
QUALITY ACCREDITATION DEPARTMENT
MM.6 The Hospital has a system for the safety of look-alike
and sound-alike Medications (LASA)
Intent:
Medication errors related to look-alike and /or sound-alike medication names are
common in the health care setting throughout the medication use process.
Look-alike , sound –alike medications account for an estimated 25-30% of all
medication errors.
With tens of thousands of medications currently on the market, the potential for
serious errors due to confusing medication names is significant. Contributing to
this confusion are incomplete knowledge of drug names; newly available
products; similar packaging or labelling; similar clinical use ; illegible
prescriptions or misunderstanding during issuing of verbal orders.
world wide organizations such as the WHO and the ISMP had identified,
published and periodically updated several lists of LASA medications.
The Hospital shall initiate and annually update their own list of LASA Medications
names.
The Hospital should establish scientific based safety strategies to prevent or
minimize errors with such medications.
QUALITY ACCREDITATION DEPARTMENT
ME# MEASURABLE ELEMENTS ACTIVITY EVIDENCE
Review Policy:
MM.6
6.1 TheisHospital
There has policy
a multidisciplinary a system for the
and procedure on safety of look-alike and sound-alike
handling look- alike/sound-alike (LASA) medications. Document Review
(LASA)
Look-alike/Sound-alike Drugs
medications. (LASA)
6.2 The hospital reviews and revises annually its list of
confusing drug names, which include LASA medication List of LASA M–medications
name pairs that the hospital stores, dispenses, and Document Review updated annually
administers. Attached to policy
6.3 The hospital takes actions to prevent errors involving LASA
medications including the following, as applicable:
6.3.1 Providing education on LASA medications to healthcare
professionals at orientation and as part of continuing
education. review
Evidence of
6.3.2 Using both the brand and generic names for prescribing
Adequate # of staff receiving
LASA medications.
education material ; attendance
6.3.3 Writing the diagnosis/ indication of the LASA medication
on the prescription. Staff interview & Observation
Observation
Evidence of error prevention
6.3.4 Changing the appearance of look-alike product package. Document Evidence
strategies due to LASA.-
Staff Interview
Mandatory Competencies for
6.3.5 Reading carefully the label each time a medication is nurses, doctors and pharmacists
accessed, and/or prior to administration. - every 2 years record for LASA
medications.
6.3.6. Minimizing the use of verbal and telephone orders. -attendance records.
6.3.7 Checking the purpose/indication of the medication on the
prescription prior to dispensing and administering.
6.3.8 Placing LASA medications in locations separate from each
other or in non-alphabetical order
QUALITY ACCREDITATION DEPARTMENT
MM.41 The hospital has a process for monitoring, identifying, and
reporting significant medication errors, including near misses,
hazardous conditions and at risk behaviors that have the potential to
cause patient harm
Intent:
Medications errors compromise patient confidence in health care system and
increase the costs of health care provision.
Some medication errors result in serious harm and results in increased
patient morbidity or Mortality.
The fundamental purpose of medication error reporting system is to learn
how to improve the medication use and prevent errors reoccurrence.
Medication errors are probably undetected and under reported.
Reporting of medication errors must become culturally accepted throughout
the health care system.
A major investment of resources will be required in the health care system to
apply the lessons learned from the reporting of medication errors.
Medication error reporting system should include Near Misses, hazardous
conditions and At Risk Behaviors.
QUALITY ACCREDITATION DEPARTMENT
MM.41 The hospital has a process for monitoring, identifying and
reporting significant medication errors, including near misses,
hazardous conditions and at risk behaviors that have the potential to
cause patient harm.
ME# MEASURABLE ELEMENTS ACTIVITY EVIDENCE
41.1
There is a multidisciplinary policy and procedure on
handling medication errors, near misses, and Policy review:
Document Review
hazardous situations (e.g. confusion over look- Medication Errors Policy
alike/sound-alike drugs or similar packaging).
41.2 The policy has a clear and acceptable definition of Policy review:
significant medication error, near misses and hazardous Document Review Medication Errors Policy
situations.
41.3 The treating physician is notified of the medication Timeliness of reporting.
Staff Interview
error at the appropriate time.
41.4 Medication error reporting is completed within the Timeliness of reporting
Staff Interview
specified time frame after discovery of the error.
41.5 The hospital has a standard format for reporting
Document Review Medication Errors Reporting System
medication errors.
41.6 Staff are educated on the process and importance of [Link]
Staff Interview
medication error reporting. [Link]/
41.7
There is active reporting of medication errors, near -Review Medication Errors reports;
Document review.
misses, and hazardous situations. Reporting System-datix system.
41.8 The hospital conducts intensive root-cause analysis RCA of all significant or potentially
for all significant or potentially significant medication Document Review significant medication errors.
error (Sentinel Event Review Process)
QUALITY ACCREDITATION DEPARTMENT
ME# MEASURABLE ELEMENTS ACTIVITY EVIDENCE
41.9 MRR
selected cases of reported
Medication errors, near misses, and hazardous
medication errors
situations are documented in the patient’s medical Open medical record review
-Required documentation in
record.
MR; minimum medication errors
that reach the patient.
41,10 The hospital utilizes reported data to improve the
medication use process, prevent medication errors, Pharmacy and Therapeutics
Document review/Pharmacy and
and improve patient safety Committee Meeting Minutes
Therapeutics Committee
- evidence of analysis the event
Interview
, corrective action plan
41.11 Healthcare professionals are provided with feedback Interview
on reported medication errors, near misses, and -Staff that have reported
hazardous situations. medication errors; receive
Staff Interview feedback accordingly
-or unit feedback.
41.12 The hospital reports sentinel events related to
Evidence of reporting
serious medication errors to the relevant authorities.
sentinel events related to
serious medication errors to the
relevant authorities.
Document Review
-interview of members of
PTC committee on the process
of reporting sentinel events.
QUALITY ACCREDITATION DEPARTMENT
Thank you!
QUALITY ACCREDITATION DEPARTMENT