Standard MEDICATION MANAGEMENT AND USE

176 Operation Policy In Obstetrics and Gynaecology Services OPERATIONAL POLICIES Intent of 22.2 1. A qualified individual directly supervised the activities of the pharmacy or pharmaceutical service. 2. The individual is appropriately licensed, certified, and trained pharmacist. Measurable elements 22.2 1. An appropriately licensed, certified and trained individual supervises all activities at the pharmacy. 2. All prescription are checked for appropriate chemical name, dose and duration. 3. List A drugs are appropriately countersigned . Compliance to practice standards Std: 100 22.3 Standard An appropriate selection of medications for prescribing or ordering is kept in stock and made readily available. Intent of 22.3 1. Department has available medication for prescribing and ordering 2. Medication selection considers patient need and safety as well as economics. 3. The pharmacist shall notify prescribers of the shortage and suggested substitutes. 4. The pharmacist on a 3 monthly basis will inform the Head of Department and Head of Units regarding further request for drugs, budget and drugs not utilized. 177 Operation Policy In Obstetrics and Gynaecology Services Measurable elements of 22.3 1. Medications available for prescribing and ordering are appropriate to department’s mission, patient needs and services provided. 2. There is list of medication available for the department. 3. There is a process to notify prescribers of the shortage and suggested substitutes. 4. All list A drugs countersigned by appropriate consultant Compliance to practice standards Std: 100 22.4 Standard Medications are properly and safely stored Intent of 22.4 1. Medications may be stored at patient care unit or wards. 2. Refer Guideline on Management of Drugs in the Ward : Pengendalian Ubat- ubatan di Wad 3. Ensure that all medications require a cold chain and are stored according to the requirements in the ward and clinic. Measurable elements of 22.4 1. Medications are stored under conditions suitable for product stability 2. Controlled substances are accurately accounted for according to hospital policy. OPERATIONAL POLICIES 178 Operation Policy In Obstetrics and Gynaecology Services 3. Medications are accurately labelled with contents, expiration date and warnings. 4. All medication storage is periodically inspected by the pharmacist according to hospital policy to ensure medications are stored properly. Compliance to practice standards Std: 100 22.5 Standard Emergency medications are available, monitored and safely stored Intent of 22.5 1. In emergency situations, quick access to appropriate emergency medications is essential. i. Emergency medications shall be kept in the emergency trolley ii. The medications shall be checked by the staff nurse in charge in every shift to ensure availability and documented properly. The medications are replaced when used, damaged or out of date. Measurable elements of 22.5 1. Emergency medications are available in the units and readily accessible to meet the emergency needs. 2. Emergency medications are monitored and replaced in a timely manner after use or when expired or damaged. 3. Documentation of who signed and verified the medications with changes made or noted on the medication expiry present in a log book. Compliance to practice standards Std: 100 Absence of expired drugs in the emergency trolley Std: 100 OPERATIONAL POLICIES 179 Operation Policy In Obstetrics and Gynaecology Services OPERATIONAL POLICIES

22.6 Standard

Prescribing, ordering and transcribing are guided by the hospital policy Intent of 22.6 1. Safe prescribing, ordering and transcribing are guided by the hospital policy. 2. Prescribing has to be in the chemical name of the drug. Measurable elements of 22.6 1. Staff shall adherent to correct prescribing, ordering and transcribing practices Compliance to practice standards Std: 100 22.7 Standard Prescription needs to be complete and accurate Intent of 22.7 1. To improve patient safety, complete order of prescription required : a. Patient’s identification name, IC no, RN b. The medication required chemical name c. Frequency and duration of medication needed od, bd,tds d. Prescription shall be signed clearly 2. Medication shall not be released by the pharmacy if there is incomplete, illegible or unclear medication order. Measurable elements of 22.7 1. Medication order or prescriptions are complete and accurate. Compliance to practice standards Std: 100 Percentage of queried prescriptions Std: 5 180 Operation Policy In Obstetrics and Gynaecology Services OPERATIONAL POLICIES

22.8 Standard