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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.