2005 Edition Report on Drug Administration Procedure & Practices ...

More documents

Recommendations

Info

4.72 Special precautions should be taken in situations such as replenishment of re-packed drugs,drugs from the ward return and medications not picked up by patients, etc.Pharmacy Service Hours4.73 In order to improve the quality of services, round-the-clock pharmacy services wereintroduced in QMH, PMH and TMH in October 2001. The 24 hours pharmacy serviceshould be further rolled-out to all acute general hospitals when resources are available.Ward Stock Supplies4.74 To maintain the continuity of drug supplies outside pharmacy service hours and for variousother operational reasons, ward stocks will still be required to facilitate the process of supplyand administration of medications to patients. In order to maintain a proper ward stocksystem, the following points should be considered :(a) The reasons for keeping ward stocks must be well established. The items included in theward stock list must be appropriate to the practice/activity of each individualspecialty/unit.(b) Particular caution should be exercised regarding the drug items that have commonlybeen involved in potential medication errors, such as concentrated forms of drug itemsthat required dilution into larger volume, e.g. concentrated KCl injection (refer toAppendix 6). These drug items should not be kept as ward stock in general care areas.All ward stock items must be supplied in appropriate labelled containers.(c) The range of ward stocks and the quantity kept for each item should be minimised. Theward stock item level should be updated periodically.(d) A list of ward stock items should be maintained and periodically reviewed. Anyunnecessary items should be deleted. The addition of any item to the list must beexamined critically.(e) Pharmacy staff should be actively involved and responsible for the whole process ofward stock management e.g. by using a bar-code topping up system.(f) In the absence of barcode topping up system due to resource constraints, the “two bottlesystem” should be employed. This will help the nursing staff monitor the levels of wardstocks more easily.Emergency Drug Supplies outside Pharmacy Service Hours4.75 When a 24 hours pharmacy service is not feasible, access to a limited supply of medicationsfrom the Night Cabinet should be available to doctors or nursing staff for use in initiatingurgent medication orders. For the “Cluster Pharmacy Model”, an effective and efficientward stock replenishment system and special arrangement for ad hoc / urgent requirementsmust be in place.31
4.76 A small quantity of the drug items should be kept in the night cabinet which is kept lockedwhen not in use. The drug items to be kept in the night cabinet, should be chosen with safetyin mind. The container for each item should be labelled with the drug’s name, strength,quantity, expiry date and retraceable lot number.4.77 Where an emergency drug supply is made and a prescription is to be provided later, amedication order must be made at the time of emergency drug supply. Such medicationorder should be verified by the pharmacy staff and the drug item replenished within 24 hours.Supply of Antidotes and Detoxifying Agents in HA hospitals4.78 Certain antidotes and detoxifying agents are stocked by some HA hospitals (refer toAppendix 7). Clinical departments should check with their hospital pharmacies for the mostupdated version of the list. Arrangement should be made through the hospital pharmacy ifany of these agents are required.Supply of Medications for Patients during Inter-hospital Transfer4.79 The continuity of drug supply must be considered as the top priority regarding the supply ofmedications for patients during inter-hospital transfers. The medications should be properlylabelled. The detailed HAHO guidelines are shown in Appendix 8.(C) RECOMMENDATIONS ON THE DELIVERY / STORAGE OF DRUGSDelivery of Drugs4.80 Delivery of drugs includes the drugs delivered to within and outside (Cluster PharmacyModel) the hospitals. Hospitals should continue to improve their existing facilities fortransportation of drugs to prevent possible misappropriation or tampering by the use oflocked receptacles. Plastic seals with control number printed on each seal or combinationlocks can be used.4.81 For the “Cluster Pharmacy Model”, designated personnel to handle the drug delivery / pickupare recommended. Use of different coloured / colour-coding receptacles for differenthospitals should help to minimize the chances of mix-up of drugs delivery between hospitals.4.82 Separate receptacles should be used for refrigerated items and cytotoxic drugs. Auxiliarysigns to accompany items that require special handling instruction, such as “drugs requiredrefrigeration” and “CHEMOTHERAPY — HANDLE WITH CARE, DISPOSE OFPROPERLY”, in both English and Chinese should be made available.Storage of Drugs4.83 All drugs must be stored under suitable conditions, appropriate to the nature and stability ofthe drug concerned. They must be protected from contamination, sunlight, atmosphericmoisture and adverse temperatures, kept in safe custody with locks.32
Page 2 and 3: ForewordMedication safety and provi
Page 4 and 5: Chapter 6 summarizes the specific r
Page 6 and 7: Chapter 6Conclusions and Recommenda
Page 8 and 9: CHAPTER ONETHE WORKING GROUPMEMBERS
Page 10 and 11: CHAPTER TWOTHE PROGRESS REPORT2.1 P
Page 12 and 13: CHAPTER THREEAREAS FOR IMPROVEMENT
Page 14 and 15: Existing In-patient Drug Administra
Page 22 and 23: CHAPTER FOURRECOMMENDED PRACTICES A
Page 24 and 25: Drug Name4.11 There should be a hos
Page 26 and 27: Electronic prescribing (Medication
Page 28 and 29: 4.46 When the use of CM is permitte
Page 30 and 31: cytotoxic and central intravenous a
Page 34 and 35: 4.84 To prevent mixing up medicatio
Page 36 and 37: The Principle of Three checks and F
Page 38 and 39: 4.111 Three-way (red and blue) and
Page 40 and 41: or their discharge or death, should
Page 42 and 43: operational requirement but also it
Page 44 and 45: Quality Complaints on Pharmaceutica
Page 46 and 47: LEVELSHAHOCE / DTOOLS & MECHANISMDU
Page 48 and 49: Medication Incident Report<
Page 50 and 51: Continuing Education6.18 In order t
Page 52 and 53: APPENDICESAppendix 1Appendix 2Appen
Page 54 and 55: Hospital Authority Hospital No. : I
Page 56 and 57: Sensitivity:Prescription/ routewith
Page 58 and 59: Appendix 3aLists of HA-wide Approve
Page 60 and 61: DRUGTeniposideABBREVIATIONVM-26Thia
Page 62 and 63: Appendix 3b“Do Not Use Abbreviati
Page 64 and 65: Appendix 4Schedule for the Administ
Page 66 and 67: Appendix 5Mechanism for the Managem
Page 68 and 69: 4. As with all medications, there s
Page 70 and 71: Appendix 6HA Guideline on Safe Mana
Page 72 and 73: 2.1 Concentrated potassium chloride
Page 74 and 75: Appendix 7Supply of Antidotes and D
Page 76 and 77: 複本 Antidotes and emeg drug lis
Page 78 and 79: Appendix 8Guidelines for Supply of
Page 80 and 81: substitution with other drugs in ac
Page 82 and 83:
Appendix 9Samples of the Line Label
Page 84 and 85:
Appendix 10Guidelines on the use of
Page 86 and 87:
Appendix 11Guidelines on Patient Se
Page 88 and 89:
Operational Guidelines7. The operat
Page 90 and 91:
COC(N) Paper 12/2004Approved by COC
Page 92 and 93:
7.4 Evaluation Record and report th
Page 94 and 95:
DISPOSAL OF HOSPITAL PHARMACEUTICAL
Page 96 and 97:
Appendix 14Guidelines on the Handli
Page 98 and 99:
Appendix 15Medication Incident <str
Page 100 and 101:
Hospital Authority Medication Incid
Page 102 and 103:
QUALITY ASSURANCE IN DRUG THERAPYHO
Page 104 and 105:
Fig. 1: ADR voluntary reporting sys
Page 106 and 107:
PROCEUDRE FOR QUALITY COMPLAINTSONP
Page 108:
Part II Procurement Section, CPO1.
show all

2005 Edition Report on Drug Administration Procedure & Practices ...

Create successful ePaper yourself

Delete template?

Save as template?