A Self-Assessment Guide for Health Care Organizations - IFC

Standard QMI.4 [Medications use]
Medications use complies with applicable laws and regulations and is efficiently organized to meet patient needs.
Intent of QMI.4
Medications, as important resources in patient care, must be organized effectively and efficiently. Medication management is not only the
responsibility of the pharmaceutical service but also of managers and clinicians. How this responsibility is shared depends on the organization’s
structure and staffing. In those cases where a pharmacy is not present, medications may be managed on each clinical unit according to
organization policy. In other cases, where a large central pharmacy is present, the pharmacy may organize and control medications throughout
the organization. Applicable laws and regulations are incorporated into the operation of the medication management system. To ensure
efficient and effective medication management and use, the organization conducts a systems review at least once a year. The review includes
the medications selection and procurement, storage, ordering and transcribing, preparing and dispensing, administration and monitoring.
The review considers evidence-based practices, monitoring activities, documentation of improvements, and safety systems.
Measurable Element Look for Score Observations
What is required
1) Policies guide all
phases of medication
management and
medication use in the
organization, including:
a. when generic or brand
names are acceptable
or required,
b. the data necessary to
accurately identify the
patient,
c. the required elements
of the order or
prescription,
d. whether or when
indications for use are
required on a PRN (pro
re nata, or “as
needed”) or other
medication order,
e. special precautions or
procedures for
ordering drugs with
look-alike or soundalike
names,
f. actions to be taken
when medication
orders are incomplete,
illegible, or unclear,
How is this element
assessed
A set of medication policies and
procedures address all the required
elements. There is evidence that
the there is compliance with the
policies and procedures. A
multidisciplinary team guides the
formulation, implementation,
review and improvement of
medication policies and procedures.
0 5 10 Why did you give this score
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IFC Self-Assessment Guide for Health Care Organizations 49