MMU Question and Answers

Category
SN Questions/Areas surveyed Remarks

1. What is medication reconciliation?  Medication Reconciliation: formal process for creating the most complete and accurate list
Why is it done? possible of a patient’s current medications and comparing the list to those the patient has
Who does medication reconciliation? been taking.
When do they do medication reconciliation  It is done to avoid any duplication, omission & potential interaction
 Physicians
 At the time of admission, discharge and transfer

2. Is indication required when a PRN medication is prescribed? Yes

Staff able to explain a complete PRN order PRN orders include indication, frequency and duration of treatment while prescribing
**No ranging is allowed while prescribing PRN orders.
3. Do you take verbal/telephone orders? Telephone orders are not allowed
What is your policy? Verbal order must only be accepted during an emergency in the
Prescription presence of the physician

4. How do you take verbal order? Write it down and readback to the physician giving the order.
Verbal orders for medications must include:
 Name of the medication,
 Dosage of the medication dictated in words
 route of administration
 frequency

In case writing down/documenting in Salama is not possible e.g.: during Code blue: repeat back can
replace read back.

5. Who is allowed to prescribe narcotic medication? Only DHA Physicians except residents and interns

6. What is the validity of narcotic medication prescription  Regular orders for narcotic medications are valid for 48 hours after which a new narcotic
 order shall be written.
 PRN orders for narcotic medications received from all departments are valid for 24 hours
only.
 STAT/Single-dose orders for narcotics medications are valid ONCE ONLY.
7. Do you perform the appropriateness review before Pharmacist verifies and will be reflected in the Salama
administration? How do you check the appropriateness of the
Verification order?
8. Do you have references to do the checking, software programs? Yes
are they accessible? Micromedex in e-library (refer tip sheet send in batch 2)
9. Do you have drug formulary? DHA Drug Formulary 2021 and 2022

10. In case of emergency when the pharmacist is not available to Physician

check and the nurse took the medication from ward stock, who
will verify the order?
11.  Regular Medication: within 2 hours.
 PRN medications: within 1 hour.
What is the acceptable time frame for receiving medication  STAT Order: within 30 min.
from pharmacy? If it not an ADC item? After which will be considered as medication error
Note:
If medication available in the Emergency, ADC or Floor Stock it must be administered immediately
when it is due once verified.
12. What to do if Omnicell is out of order Notify Pharmacy to supply unit dose medication
Dispensing

What is the approved time frame of medication administration Prescribed medicines shall be administered at the due time specified by the physician. Medicine
13. administration time may range from 60 minutes before to 60 minutes after due time. Any
administration earlier or later to that will be considered a medication error
14. Do you allow the patient to bring in his medicine and use it in Yes.
the hospital
15. What is your process for handling medication brought by the Physician verifies and places medication order in SALAMA system as Non-Formulary item with
patient? complete drug and administration information.
Nurse labels the patient’s medicine with the patient name and MRN sends medication to pharmacy
for verification.
Administration Pharmacist verifies medication and sends back to the unit.
Nurse stores the medication in the unit according to recommended storage condition and returns
medication to the patient/next of kin upon discharge
16. Do nurses prepare IV admixtures, is there an assigned area in Yes
the ward? The preparation of pharmaceutical product which requires the measured addition of a medication to a
 50 ml or greater of IV fluid.
What is IV admixture?
17. How do you withdraw medication from an ampoule? Using blunt filter-needle

18. How do you identify patient? Name and MRN

What is the process if a patient wishes to self-administer his All medications to be self-administered are kept under control of the nurse.
medication? Patient Self-administers the medicine in the presence of a nurse.
19.
Educate patient
Document in the patient's record that the patient self-administered his/her medications
Which medicines can the patient self-administer? Medications that can be self-administered by the inpatients in the wards are:
 External use preparations.
20.  Eye, ear and nasal preparations
 Inhalers.
 Insulin preparations.
During Salama downtime, the process of the medication Access BCA PC, print downtime MAR form and physician will prescribe the order on it.
prescription and administration Filled MAR form is either faxed or send through messenger to pharmacy.

21.

Process for administering Narcotic medication Preparation to be done in the presence of a witness by a staff nurse or Physician.
Only Physicians and staff nurses shall administer narcotic medications, only upon the completion of
a narcotic drug order (NDO) (DHA-72) by a physician except in an emergency situation.
- In an emergency situation, narcotic drug order (NDO) (DHA-72) shall be completed within one
22.
hour or when the emergency is over (whatever is earlier).
The Narcotic medications shall be administered in the presence of another staff nurse, technician or a
physician as a witness.
The nurse and witness shall sign in the Narcotic Drug Register (DHA-73).
23. How do you handle narcotic wastage  Any unused remainder shall be recorded in narcotic drug register (DHA-73), narcotic
drug order (DHA 72) and discarded in the washbasin and flushed with water in the
presence of a witness by staff nurse, technician or physician.
 Process for replacing narcotic medications For all parenteral forms of narcotic medications, empty ampoules/vials shall be kept for submission
24. upon exchange along with the completed narcotic drug orders.
How do you dispose narcotic patches?  Used narcotic patches are discarded in the ward by folding the sticky sides together and
25. dispose of in biohazard containers.
Do you educate your patients about medications Yes, upon administering the first dose, in SALAMA.
26. Refer MAR and Education
27. Is medication room controlled by coded access/kept closed Yes

Storage
28. Is hygrometer available in pharmacy? Check log maintained Yes
with action plan?
29. Where do you store the flammable items In Hazardous material cabinet.

Temperature limits for medicine refrigerator Between 2-8 degree Celsius

How frequently do you check the temperature of the drug Every day at the beginning of each shift.
30.
fridge? Permanently in the unit.
How long do you keep the record in the Unit?
What to do, if you find that the temperature is out of range? If the temperature is out of range:
 Transfer medications/Contents immediately to another refrigerator and segregate then from
other stock.
31.  Inform the engineering department Document action taken in Action plan. Report incident
through AMAN system

7 Rights of Medication Administration Right patient, right drug, right dose, right route, right time, right to educate and right documentation.
32.

33. How often is the PPM done for the drug refrigerators Yearly

34. How are the narcotics stored in units? In double locked narcotic cabinets.
Who takes care of the two keys? First key with the Team Leader and second key with another Registered Nurse.
35. Process to be followed in an event of failure by any one or both  The duplicate keys in custody of the security services should be used to access the narcotic
the nurses to hand over the keys at the end of their shift medicines, if there is a need for narcotic medications.
 The narcotic cabinet in the unit should be opened in the presence of security and two
registered nurses.
 After removing the required narcotic medication, the cabinet shall be locked and duplicate
 keys placed in a envelop, sealed and hand over to security.
 An investigation to be initiated in this regard by respective administration in case duplicate
keys were used to access narcotic medication
36. Are there any medications stored in the wards (ward stock) Floor stock & Emergency meds

37. How often the pharmacist does the inspection of the medication Monthly Inspection.
room in the units Monthly Inspection record available in the Unit shareholder
(Oct 2021-Nov 2022)
38. What is a medication recall? Medication recall occurs when a drug is removed from the market because it is found to be either
defective or potentially harmful. Defects to a medication may be related to incorrect packaging,
potential contamination, or poor manufacturing, resulting in impurities or errors in strength/potency.
39. How do you handle medication recall Once notified by the Pharmacy department about any recalled medication, carefully inspect patient
medication storage areas (except ADC) on the unit and return recalled medication to the pharmacy.
What do you do if the medication has short expiry date, what to Near-Expiry Medicines: Are those medicines which have an expiration date within the next six
do if you find expired medication in the unit? months.
40. Inform the Pharmacy Section about any expired medicine available in the units and return medication
to the pharmacy.

41. How long do you use a multidose vial? According to the manufacturer recommendations or 28 days

42. How do you store High Alert medications? HAM will be kept in a locked cabinet segregated from another floor stock and clearly labeled "High
Alert". The key will be kept in possession of the in-charge nurse/designee
 Oral dosage forms of HAM will be kept locked in the Omnicell.
 HAM in crash cart should be kept inside separated clear labeled bag
 Refrigerated HAM are segregated from other stock in the medical fridge and clearly labeled
with "High Alert" sticker.
43. Process for handling HAM Medication administration HAM must be independently double checked by 2 nurses.
 Laboratory results should be double-checked prior to administration of HAM. (Example,
Check APTT prior to administration of Heparin)
 Only physicians can administer IV Contrast media [ Undiluted Bolus Form]
44. How do you identify LASA medication? Identified list of LOOK ALIKE AND SOUND ALIKE are flagged in MAR in SALAMA.
Can you explain?  Segregate Look –Alike and Sound Alike medications.
 Carefully read the label each time the medication is accessed and again prior to
administration, rather than relying on visual recognition, location or other less specific cues.
 Check the purpose of the medication on the order prior to administering the medication
45. Storage of insulin and heparin vials  Insulin vials before opening store in refrigerator and after opening store in high alert
cupboard.
 Heparin vials to be stored in high alert cupboard before and after opening the vials

46. How do you manage Food Drug interaction Medications identified will be labelled with Food Interaction label
Nurse then educates patient by referring to the Food Drug interaction list

47. Who will check the emergency medications in the crash Pharmacist
trolley? Monthly
How often?
How do you ensure safety of the emergency medications in the All crash carts and CPR Bags are secured all times by a numbered plastic lock.
crash trolley, how to protect them from loss & theft Two crash cart keys are available:
 Key 1 is kept in the main drug compartment of the crash cart, which is secured with the
Plastic Lock.
 Key 2 is kept with the Shift In-Charge/Delegate.
48.
If the crash cart lock has been tampered with or is inconsistent with recorded lock number complete
checking of the crash cart will be done.
Inspect the integrity of the seals of the resuscitative medication carts and blue box/ tray/ bags once a
week to prevent loss, theft or unnecessary usage of medications.
Inform Pharmacist if the seal is broken
49. How long it takes to replace the emergency medication once it Within one hour
is used up
50. How do you handle discharge medications? Medications supplied in patients name will be removed and kept in the medication room and returned
to the pharmacy through messenger
51. Reporting Types of medication errors Errors in Prescribing, transcribing, labeling, packaging, dispensing, administration, education,
monitoring and use
52. Do you have policy for Medication error? Yes

53. What is your process of reporting the medication error Take immediate actions to correct medication error/ near miss when identified
Report Medication errors and near electronically through AMAN System within 24 hours of
identification of the medication error.
54. What is your process of reporting the adverse drug reaction Inform physician immediately, if any adverse drug reaction is identified.
Physician fills the ADR reporting form in AMAN system within 24 hours and provides feedback to
patients and family members about ADRs and action taken.
55. Staff able to explain the process in case of narcotic incident Unused opened vial/accidental breakage of narcotic medication a narcotic incident form is filled and
occurs signed by a witness.
Nursing Supervisor, Nursing and Hospital Director and Head of Pharmacy Section