Medication Management and Use System Tracer tool

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standards/Measurable Elements

A written document addressing items a) through h) of the intent as appropriate, identifies how medication use is organized and managed throughout the hospital
All settings, services, and individuals who manage medication processes are included in the organizational structure
A licensed pharmacist or other qualified individual directly supervises the activities of the pharmacy or pharmaceutical service
There is at least one documented review of the medication management system, addressing items a) through h) of the intent as appropriate, within the previous 12 months
The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations
Appropriate sources of drug information are readily available to those involved in medication use
The hospital develops and implements a program for antibiotic stewardship that involves infection prevention and control professionals, physicians, nurses, pharmacists, trainees, patients, families, and others
The program is based on scientific evidence, accepted practice guidelines, and local laws and regulations
The program includes guidelines for the optimal use of antibiotic therapy for treatment of infections, including the proper use of prophylactic antibiotic therapy
There is a mechanism to oversee the program for antibiotic stewardship
The effectiveness of the antibiotic stewardship program is monitored

SELECTION AND PROCUREMENT

There is a list of medications stocked in the hospital or readily available from outside sources
The process used to develop the list (unless determined by regulation or an authority outside the hospital) includes representation from all those who prescribe and manage medications in the hospital
There is a process for obtaining medications during the night or when the pharmacy is closed
There is a method for overseeing medication use in the hospital
Health care practitioners involved in ordering, dispensing, administering, and patient-monitoring processes are involved in evaluating and maintaining the medication list
Decisions to add or to remove medications from the list are guided by criteria
When medications are newly added to the list, there is a process or mechanism to collect, aggregate and monitor data on how the drug is used and any unanticipated adverse events
The list is reviewed at least annually based on safety and effectiveness of use information

STORAGE

Medications are stored under conditions suitable for product stability, including medications stored on individual patient care units and ambulances (as applicable)
Controlled substances are accurately accounted for according to applicable laws and regulations
Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings
All medication storage areas, including medication storage areas on patient care units and ambulances (as applicable), are periodically inspected to ensure that medications are stored properly
Medications are protected from loss or theft throughout the hospital
The hospital establishes and implements a process that includes a) through e) of the intent, for nutrition products
The hospital establishes and implements a process that includes a) through e) of the intent, for radioactive, investigational, and similar medications
The hospital establishes and implements a process that includes a) through e) of the intent for sample medications
The hospital establishes and implements a process that includes a) through e) of the intent for medications brought in by the patient
Emergency medications are available in the units where they will be needed or are readily accessible within the hospital to meet emergency needs
The hospital establishes and implements a process for how emergency medications are uniformly stored, maintained, and protected from loss or theft
Emergency medications are monitored and replaced in a timely manner after use or when expired or damaged
There is a medication recall system in place
The hospital establishes and implements a process for use of unopened, expired medications and outdated medications
The hospital establishes and implements a process for the destruction of medications known to be expired or outdated

ORDERING AND TRANSCRIBING

The hospital establishes and implements a process for the safe prescribing, ordering, and transcribing of medications in the hospital
The hospital establishes and implements a process for managing illegible prescriptions and orders, including measures to prevent continued occurrence
Staff are trained in correct prescribing, ordering, and transcribing processes
The patient’s medical records contain a list of current medications taken prior to admission or registration as an outpatient, and this information is made available to the patient’s health care practitioners and the pharmacy as needed
Initial medication orders are compared to the list of medications taken prior to admission, according to the hospital’s established process
The required elements of complete medication orders or prescriptions include at least as appropriate to the order
The data necessary to accurately identify the patient8 (Also see IPSG.1)
The essential elements of all orders or prescriptions
When generic or brand names are acceptable or required
Whether or when indications for use are required on medication orders, including PRN (pro re nata, or “as needed”) orders
The types of orders that are weight based or otherwise adjusted, such as for children, frail elderly, and other similar populations
Rates of administration when intravenous infusions are ordered
Other special orders such as titrating, tapering, or range orders
The hospital develops and implements a process to manage medication orders that are incomplete, illegible, or unclear
The hospital develops and implements a process to manage special types of orders, such as emergency, standing, or automatic stop, and any elements unique to such orders
The hospital develops and implements a process to monitor the completeness and accuracy of medication orders and prescriptions
Only those permitted by the hospital and by relevant licensure, laws, and regulations prescribe or order medications
The hospital establishes and implements a process to place limits, when appropriate, on the prescribing or ordering practices of individuals
Individuals permitted to prescribe and to order medications are known to the pharmaceutical service or others who dispense medications
Medications prescribed or ordered are recorded for each patient
Medication administration is recorded for each dose
Medication information is kept in the patient’s medical record or inserted into his or her medical record at discharge or transfer

PREPARING AND DISPENSING

Medications are prepared and dispensed in clean, uncluttered, safe and functionally separate areas with appropriate medical equipment, and supplies
Medication preparation and dispensing adhere to laws, regulations, and professional standards of practice
Staff preparing sterile products or preparing medications using multi-dose vials are trained in the principles of medication preparation and aseptic techniques
The hospital defines the patient-specific information required for an effective review process, and the source or availability of this information is available at all times when the pharmacy is open or closed
Apart from exceptions identified in the intent, each prescription or order is reviewed for appropriateness by a licensed professional competent in the knowledge required to perform a full appropriateness review prior to dispensing and administration and includes elements a) through g) in the intent
Individuals permitted to conduct appropriateness reviews are judged competent to do so and are provided resources to support the review process
When the designated licensed professional is not available to perform the full appropriateness review, a trained individual conducts a review of critical elements h) through k) in the intent for the first dose and a full appropriateness review is conducted by the designated licensed professional within 24 hours
Review is facilitated by a record (profile) for all patients receiving medications, and this record is available at all times when the pharmacy is open or closed
There is a uniform medication dispensing and distribution system in the hospital that complies with local and regional laws and regulations
Medications are dispensed in the most ready-to-administer form available
The system supports accurate and timely dispensing and documentation of dispensing practices
After preparation, medications not immediately administered are labeled with the name of the medication, the dosage/concentration, the date prepared, the expiration date, and two patient identifiers

ADMINISTRATION

The hospital identifies those individuals, by job description or the privileging process, authorized to administer medications
Only those permitted by the hospital and by relevant licensure, laws, and regulations administer medications
There is a process to place limits, when appropriate, on the medication administration of individuals
Medications are verified with the prescription or order
The dosage amount of the medication is verified with the prescription or order
The route of administration is verified with the prescription or order
Patients are informed about the medications that they are going to be given and have an opportunity to ask questions
Medications are administered on a timely basis
Medications are administered as prescribed and noted in the patient’s medical record
The hospital establishes and implements a process to govern patient self-administration of medications
The hospital establishes and implements a process to govern the management, use, and documentation of any medications brought into the hospital for or by the patient
The hospital establishes and implements a process to govern the availability, management, use, and documentation of medication samples

MONITORING

Medication effects on patients are monitored
Medication adverse effects on patients are monitored and documented
The hospital has a process for recording in the patient medical record, adverse effects related to medication use and reporting adverse effects to the hospital
Adverse effects are documented in the patient’s medical record as identified
Adverse effects are reported as identified by the process in the time frame required
The hospital establishes a definition for a medication error and near miss
The hospital establishes and implements a process for reporting and acting on medication errors and near misses
Those accountable for taking action on the reports are identified. q 4. The hospital uses medication errors and near misses reporting information to improve medication use processes