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

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or their discharge or death, should be returned to the pharmacy. Local policies regardingward drug returns and disposal should be followed and any other required documentationcompleted.4.126 Substances prepared for administration and subsequently not used in the treatment of thepatient concerned, must be disposed of immediately. Procedures for handling of unusedrefrigerated drugs should be established. In the case of DD, this must be recorded in theledger book by both nurses involved.4.127 Antibiotics, dangerous drugs, poisons, other pharmaceutical products and cytotoxic drugs inbulk or significant residue volume 3 in container (e.g. unused or partially used drugs inampoules or syringes) are classified as Pharmaceutical Chemical Waste and should bedisposed according to the Chemical Waste Disposal Regulation. Each hospital unit shouldfollow the guidelines set up by Environmental Protection Department for disposal asstipulated in Appendix 13.(E) RECOMMENDATIONS ON HANDLING REQUIREMENTS FOR SPECIFIC DRUGSDangerous Drugs4.128 The guidelines on the handling of DD in HA hospitals was revised in April 1998. For details,Appendix 14 should be referred to.Cytotoxic Drugs4.129 Cytotoxic Drugs have both anti-cancer activity and the potential to damage normal tissues.Thus they must be handled with extreme care. Individual hospital should draw up localpolicies with regard to their handling and disposal procedures. (refer to the HA SafetyManual on Cytotoxic Drugs Safety)Hazardous Chemicals4.130 Each hospital should establish a Comprehensive Chemical Safety Programme to ensure allhazardous chemicals used in the hospital are properly managed to minimize the riskinvolved. The principles and guidelines established must comply with the OccupationalSafety and Health Ordinance (OSHO) and Subsidiary Regulations. (refer to the HA SafetyManual on Chemical Safety, Material Data Safety Sheet, reference fact sheets and theupdated version of ChemWatch)High Risk Drugs4.131 Particular caution should be exercised regarding the high risk drugs that have been involvedin potential or serious medication errors, e.g. digoxin, concentrated KCl injection. Thesedrug items should not be kept as ward stock in general care areas.3 Significant residue volume means more than 3% volume of container holding the cytotoxic drugs. Ampoules orsyringes holding less than 3% volume of cytotoxic drugs in containers can be placed in sharp boxes and disposed asGroup I Clinical Waste.39
Medications used in Resuscitation4.132 Standard lists of resuscitation medications meeting the national and international trend ofevidence based approaches in different patient groups should be defined. Pharmacologicalmanagement plans for safe and precise medication administration in different situationsshould be formulated by the hospital DTC and followed strictly in CPR.4.133 The medications used in resuscitation are stocked in the emergency trolley and emergencykit(E-kit):-(a) Medications in emergency trolleyThe medications in the emergency trolleys must be specific and consistent within the samespecialty of the cluster / hospital and they must be stored in areas with easy accessibility.The conditions and expiry dates of the medications should be checked periodically andrecords kept of such check.(b) Medications in emergency-kit (E-kit)i. All E-kits should be prepared in the pharmacy. The contents of the E-kit should beproperly labelled, concentrations of the medications standardized and layout of the E-kit consistent within the same cluster / hospital / specialty.ii.A mechanism should be in place in the pharmacy for medication replenishment andreplacement/exchange of the E-kit. Once the security lock/seal is broken, the E-kitshould be returned to the pharmacy department as soon as possible to exchange for anew one with lock/seal. A proper record should be kept in the pharmacy to monitor theexpiry dates of the medications and the location of the E-kit.4.134 Clinical staff must be well-acquainted with the medications used in CPR in terms of theirindications, dosages, units, routes of administration and other special considerations4.135 All medications ordered and administered should be documented in the MAR / resuscitationforms as soon as possible or within 24 hours of the CPR process whichever is the earlier.All orders on the MAR / resuscitation forms should be signed by the clinicians making theorders and administration signed by the nurses giving the medications.(F) INFORMATION TECHNOLOGY IN PATIENT CARE4.136 The improvement made in clinical practice, for example, in the areas of pharmacy service,through the use of information technology system, has been successfully demonstrated.This is evident in the implementation of PMS through system functions, such as thedispensing modules, the CARS, the CDDH, the Bar code Ward Stock Topping Up and theMOE etc. All these systems have significantly enhanced the efficiency of the dailypharmacy operations and have facilitated the process of drug distribution.4.137 It is noted that there is also the use and development of the CMS in the HA to support theclinical care of the patients for use by clinicians and the related parties. This systemrequires active and collaborative participation from clinicians, pharmacists and nursing staff.It can be used to review and reform operational procedures. Not only will this facilitate40
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 32 and 33: 4.72 Special precautions should be
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 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.
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