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

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Appendix 14Guidelines on the Handling ofDangerous Drugs in HA Hospitals
REVISED GUIDELINES ON THE HANDLING OFDANGEROUS DRUGS IN HA HOSPITALSProcess Authorised Staff Particulars(1) Issuance of a signedorder for the procurement ofDD from pharmacy.Ward Manager (WM) i/c;Nurse Specialist (NS) i/c;Nursing Officer (NO) i/c;Registered Nurse (RN) i/c;Enrolled Nurse (EN) (If no registerednursing staff are on-duty)Each ward to supply a list of authorizednursing staff with specimen signatures topharmacy.For practical purpose, the list should bekept small and up-dated regularly.The nursing staff issuing the signed ordershould sign and indicate her title andname clearly for verification bypharmacy staff(2) Delivery of DD to/fromwardsAs advised by the Department of Heath,the pharmacist i/c or an authorizednursing staff can appoint a designatedhospital staff acting as his/her agent forthe collection, delivery andtransportation of DD to/from wardsLockable receptacles should be used inthe transportation of DD.(3) DD records and stocks inwardsA DD register will be kept in each wardto record DD transactions.Copies of the signed order issued shouldalso be kept for the statutory 2 years.Pharmacist should inspect the DDregister and stocks in the wards monthly.Any irregularity should be rectifiedimmediately. Any irregularity thatcannot be rectified have to be reported tothe Director of Health as required underthe Dangerous Drug Ordinance.(4) Disposal of DD records The expired register and the signedorders in the wards can be disposed ofonly with the approval of the pharmacisti/c in accordance with agreed procedureswith hospitals.For administrative convenience, thepharmacist i/c will be appointed as theperson approving of the disposal.Pharmacy would work out the agreedprocedure with the nursing staff.(5) Transfer of DD from 1ward to another foremergency use after officehours when pharmacy isclosed.The designated WM, NS, RN i/c of thehospital at after-office hours should beinformed and approved of such transfer.The ‘recipient’ ward should send aqualified nurse or a student nurse to the‘donor’ ward for the collection of the DDand the MAR of the patient should bepresented. The qualified nurse in the‘donor’ ward should record the patientparticulars in its DD register.The pharmacist should be informed ofthe incident and to review the optimalward stock level.It is not necessary for the ‘recipient’ward to record the quantity of DDreceived in its register becausetechnically, the DD is only administeredto its patient and not stocked.(6) Retrieval of DD fromlocked DD cupboard inwardsWM, NS, NO and designated RN andEN who are performing the duty of thesister i/c.Should exercise 3C 5R principle.Advisable to have a second person tocountercheck.(7) Administration of DD topatients in accordance todoctors’ prescriptions ordirections in the bed cards orcase sheets.Any qualified nurse which include:Registered Nurse (General);Registered Nurse (Psychiatric);Enrolled Nurse (General);Enrolled Nurse (Psychiatric);Registered Midwife;Nurse Learner under supervision.Should exercise 3C 5R principle.Advisable to have a second person tocountercheck.7ddguide5 HAHO 17 April 981
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ForewordMedication safety and provi
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Chapter 6 summarizes the specific r
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Chapter 6Conclusions and Recommenda
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CHAPTER ONETHE WORKING GROUPMEMBERS
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CHAPTER TWOTHE PROGRESS REPORT2.1 P
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CHAPTER THREEAREAS FOR IMPROVEMENT
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Existing In-patient Drug Administra
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CHAPTER FOURRECOMMENDED PRACTICES A
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Drug Name4.11 There should be a hos
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Electronic prescribing (Medication
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4.46 When the use of CM is permitte
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cytotoxic and central intravenous a
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4.72 Special precautions should be
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4.84 To prevent mixing up medicatio
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The Principle of Three checks and F
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4.111 Three-way (red and blue) and
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or their discharge or death, should
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operational requirement but also it
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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 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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