MOM File

Management of
Medication (MOM)
Presented by
Dr. Noor e Sehar
Hospital Pharmacist
Hameed Latif Hospital
Management of Medication
• Medication Management in a hospital is the first and foremost important

step for patient care and safety.
•It is a strategy to monitor medications to ensure that they are effective, safe,
taken in proper doses, at the correct time each day, and with a focus on
improving health outcomes.
Minimum Services Delivery Standards (MSDS)
Indicators
•These are the fundamental elements that should be present in all health care
establishments in order to deliver safe health services.
•These are driven by evidence based research and designed to promote a safe
environment with managed risks.
•This benefits both patients and health care establishments and contribute to social
objectives of Punjab and the Nation.
•30 Foundation Standards and 162 associated Indicators.

MOM. 1: Policies and procedures for the prescription of
medications.
Ind 51. Policies and procedures for the prescription of
medications.
• No drug will be administered to patient without valid prescription.
Ind 52. Authority to write orders.
• Only Registered Medical Practioner (Medical & Dental)

Ind 53. Orders are written in a uniform location in the
medical records
• It creates easy accessibility to orders can be acted upon in a timely manner.
Ind 54. Medication orders are clear, legible, dated, timed,

named and signed.
1. Patient full name.
2.Weight is mandatory in
Paediatrics.
3.Allergy or
contraindicati
ons.
4. Date of
Order.
5. Name of
medicatio
n.
6.Dosage and
administration information
Ind 55. Policy on verbal orders:
 As per hospital policy, no verbal orders are allowed however, if the

patient is already examined by a consultant, then for some suggestion
and on confusion or in emergency conditions, duty doctor can consult
with patient’s consultant and can take verbal orders.
 As per policy no staff nurse can take verbal orders.
 Only one stat dose is allowed on verbal order.
 Duty Doctor will repeat it before a nurse and nurse repeat it to a
second nurse.
 Duty Doctor receiving the order must record the order on drug
treatment sheet and should also mention the time, date and name of
prescriber with red ink.
 These orders will be authenticated by consultant, who gave the

verbal orders, within 24 hours.
Ind 56. Defining a list of high-risk medication.
Drugs that bear a heightened risk of causing significant patient harm when they
are used in error. Although mistakes may or may not be more common with
these drugs, the consequences of an error are clearly more devastating to
patients.
Ind 57. Verification of High-risk medication orders

prior to dispensing.
 A list of High risk medication (high alert, expensive, highly hazard) will display all over the hospital
departments.
 High risk medicines will only be prescribed by consultants.
 Staff nurse will make the indent with his ∕ her name and send it to the pharmacy.
 Then staff nurse or Doctor will administer the medication.
 Staff nurse will administer the medication under the supervision of a Doctor or Pharmaist.
 Write on medication chart after double check and proper verification
MOM. 2: Policies and procedures to guide
the safe dispensing of medications.
• Ind 58. Policies and procedures to guide the safe storage and
dispensing of medications.
• Ind 59. The policies include a procedure for medication recall.
• Ind 60. Expiry dates are checked and documented prior to
dispensing.
• Ind 61. Labeling requirements are documented and implemented
MOM. 3: Procedures for medication
administration
Ind 62. Medications are administered (dispensed)
by those who are permitted by law to do so
 PNC authorized nurse is allowed to administer the

medication except high risk medications.
After dispensing of medication from a pharmacy, PNC nurse will double

check the medication for each patient in wards and rooms.
.
After checking ensure that environment is as safe and quite as possible.
Concentrate solely on the task in hand, inform others that you are going
to administer the medication
Wash your hand.
Staff must check the identity of patient.

Check that you have correct medication card for correct patient.
Check whether there are allergies or previous address drug

reaction recorded.
Check the instructions to administer against the packing and

medication record.
Check that whether any monitoring is required before and after
administration.
Ensure the individual is ready to receive the medication.
Staff must have authorized sheet signed by doctor or pharmacist.
Time must be listed on the medication log.

 Any equipment used in the administration process must be cleaned
and dispose off as per local protocol.
 Any error must be reported to the registered nurse or manager in
charge and incident reported in accordance with the reporting policy.
Ind 63. Prepared medications are labeled prior to
preparation of a second drug.
 Prepared medicines are labeled immediately upon preparation

including, at minimum;
• Patient Full Name and a second patient identifier (MR No.)
• Full generic drug name
• Drug administration route
• Total dose to be given
• Total volume required to administer this dosage.
• Date of administration
• Date and time of preparation
• Date and time of expiration when not for immediate use.
Ind 64. Patient is identified prior to administration.
 PNC nurse will identify the patient every time and reflect on the
patient’s record as:
1. Patient name
2. M.R #
3. Age
4. Address
5. In case of unconscious
patient identification band
will be mandatory
6. I. D band
Ind 65. Medication is verified from the order prior to administration.
• Read the medication label carefully.

• Check spelling of medication. In case of any doubt, call pharmacist before you
give medication.
• Read the medication order carefully. Make sure that medication name on the order
matches the medication name on the label.
• Read the medication log carefully.
• Look at the medication. If there is anything different about the size, shape or color
of medication, call the pharmacist before you give.
• All high risk medication which can cause serious reaction, should be checked for
hypersensitivity reaction before administration e.g. Penicillin
Ind 66. Dosage is verified from the order prior to
administration.
 The Right dose is how much of medication you are supposed to give the individual at one time.
 To Ensure Dose Verification SOP by comparing the dose on the:

• Prescription Label
• The Medication Order
• The Medication Log
Ind 67. Route is verified from the order prior to
administration.
• The use of multiple routes of administration in one prescription must be

avoided for the same high risk medicine. e.g. IV/Oral
• Ensure the following Route Verification SOP by comparing the Route on the
 Prescription Label
 Medication Order
 Medication Log
Ind 68. Timing is verified from the order prior to
administration.
• It is important to give medication at the time of day that is written on the
medication order.
• Some Medication must be administered only at very specific times of the day.
• If no specific time is written on medication order, ask the pharmacist about best
time of the day to give medication. And Note this on the medication log.
• The Dispensing Time SOP for Standard Dose Administration throughout the
hospital is that medication must be given within a ½ hour of the time that is listed
on the medication log.
Ind 69. Medication administration is documented.
 Following Instruction must be acted upon for proper documentation;
i. Each time a medication is administered, it must be documented with full name/sign.
ii. Documentation must be done at the time of actual administration.
iii. Documentation will be done with blue or black ink.
iv. No pencil or white out will be used.
v. NEVER OVER WRITE the documentation.
vi. In case of mistake in documenting the medication log, circle the mistake and write a
note on log to explain what happened.
vii. Double check the documentation after finished medication process and again at the
end of duty.
viii.Coordinate with a colleague to double check the documentation done by you to make
sure that it is complete.
Ind 70. Policies for Patient's Self
Administration of Medication:
 The self medication (SAM) is NOT allowed in the hospital.
Ind 71. Policies for Patient’s Medication
brought from outside the Organization:
 Ifsome patient brings medication from outside, the nurse on duty

will take it and lock it in a locker and will not allow the patient to
use it.
 It will be returned to the patient on discharge.

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Management of

• Medication Management in a hospital is the first and foremost important

•30 Foundation Standards and 162 associated Indicators.

• Only Registered Medical Practioner (Medical & Dental)

Ind 54. Medication orders are clear, legible, dated, timed,

 As per hospital policy, no verbal orders are allowed however, if the

 These orders will be authenticated by consultant, who gave the

Ind 57. Verification of High-risk medication orders

 PNC authorized nurse is allowed to administer the

After dispensing of medication from a pharmacy, PNC nurse will double

Staff must check the identity of patient.

Check whether there are allergies or previous address drug

Check the instructions to administer against the packing and

Ensure the individual is ready to receive the medication.

Staff must have authorized sheet signed by doctor or pharmacist.

Time must be listed on the medication log.

 Prepared medicines are labeled immediately upon preparation

• Read the medication label carefully.

 To Ensure Dose Verification SOP by comparing the dose on the:

• The use of multiple routes of administration in one prescription must be

 Ifsome patient brings medication from outside, the nurse on duty

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