MMU (Medication Management & Use) S.

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1 2 3 4 5

QUESTIONS

EXPECTED ANSWERS

YES

NO

REMARKS

Are you handling, storing and controlling the use of Narcotics Yes in your unit? Do you have any policy and country laws and regulations Yes Are you aware that there is a Medication Formulary list which Yes includes all the available medications in RH Are you aware that Pharmacy do regular rounds in your unit? Yes What system of drug administration is in process Do you have a list of medications prepared in the pharmacy EMAR Yes concentrated electrolytes anticoagulants hypoglycemics look-alike meds sound-alike meds Yes Medication errors and near-misses are reported in a timely manner using an established process

Can you tell us what are the high alert medications

Do you know what is a medication error and near-miss error? 7 Do you have a process for reporting medication error and near-miss error?

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QUESTIONS
What measures are undertaken based on the medication error and near miss data collection?

EXPECTED ANSWERS
The organization uses medication errors and near-misses reporting information to improve medication use processes.

YES

NO

REMARKS

9 10 11

Are you aware of the process for obtaining medication that is Yes not listed in the Pharmacy Medication Formulary? Do you have emergency medication in your unit? Is it Yes protected and secure? Are you aware of how to replace the emergency medication in your unit? Is there a policy for ordering, prescribing and administration of medication? Do you know the policy? Do you know where to find the policy? Which medications can be self administered by inpatients in wards? Give examples Yes (The pharmacist does when informed) Yes Yes (On File Net) Yes, External use preparations, eye, ear and nasal preps, inhalers, insulin preparations

12

13

14

How do you identify who is prescribing? Is there a process in From the prescribing physicians place to contact the Physician who prescribed the medication name number and signature

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15

QUESTIONS
Do we allow the use of sample medication? NO

EXPECTED ANSWERS

YES

NO

REMARKS

16

Do you have investigational and/or radioactive medication in Yes/ No depending upon the unit your area/unit? Do we have a policy covering investigational and radioactive medications Are you using parenteral and enteral tube nutrition therapy in your unit? Is there a policy covering the preparation, handling and storage of them? Do you label your multi-dose medication? Do you prepare your medication in a clean, dedicated and safe area? Are all medication verified BEFORE administration, including medication in Emergency Department and PRN orders? Yes Yes Yes Yes Yes Yes

17 18 19 20

21 22

Is there a process for medication recall in the hospital Yes including inpatient and outpatient? Is there a written policy? Are you aware of it? Yes Is there a process in place to dispense the medication to the Yes right patient, in the right dose, at the right time?

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23

QUESTIONS
Do you identify the patient using two identifiers, before administration of medication? Do you verify the following against the prescription before administration The dose The route The time Frequency Expiry date The correct patient? Do you monitor and document the effectiveness of the medication administered? Do you document, report and monitor Adverse Drug Reaction? Is there a policy covering this? Do you do it according to policy?

EXPECTED ANSWERS
Yes

YES

NO

REMARKS

24

Yes

25 26

Yes Yes Yes Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the Health care professionals, Patient or consumer. These events may be related to professional practice, health care products, procedures and systems, prescribing , order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use.

27

Do you know what a Medication Error is?

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28

QUESTIONS
Do you know the process to document and report medication errors? Is there a process and policy regarding medication errors? Is there a system in place to monitor medication Errors and use the information to improve medication use?

EXPECTED ANSWERS
Yes, Medication Error Reporting form will be completed and sent to the Pharmacy Section within 24 hours after identification. Yes In situation where immediate written or electronic communication is not possible and in an emergency situation Name of medication, dosage in words, route and frequency without abbreviations, name of prescribing physician, date and time of prescription, name, sign and staff number of 1st and 2nd nurse receiving the order. Within 24 hours Only during an emergency in the presence of the physician Potassium phosphate, sodium chloride>0.9%, potassium chloride 20 mmol/ 10ml, sodium chloride 5%, hypertonic saline, magnesium sulphate 50%, sodium phosphate 15mM/ 5 ml, sodium chloride 5.85% ( 20 ml ampoules).

YES

NO

REMARKS

29

31

In which situation should telephone orders be taken?

32

What does the telephone order for medication contain?

33 34

When should the telephone/ verbal order form be signed by the physician? When should a verbal order be carried out?

35

Name the high alert medications used in RH

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36 37 38 39 40 41 42 43 44

QUESTIONS
What is the expiration date for oral liquid medications? What is the expiration date for single dose vials? What is the expiration date for insulin? What is expiry date for topicals? What is expiry date for Opthalmics? What is expiry date for nitroglycerine (SL) tablets? Where is the medication error reporting form to be sent and when? Regular narcotic order is valid for how many hours? PRN orders for narcotic medications are valid for how many hours?

EXPECTED ANSWERS
30 days from opening date Discard remaining drug immediately after use 30 days from opening date 30 days from opening date 14 days from opening date 8 weeks from opening date To the pharmacy section within 24 hours after identification 48 hours 24 hours Discarded in wash basin and flushed with water in the presence of a witness and document discarded amount(wastage) in the narcotic register Dangerous drugs administration

YES

NO

REMARKS

45

What will be done with the unused balance of narcotics?

46

What is the full form of DDA?

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QUESTIONS

EXPECTED ANSWERS
Registered nurses and physicians. Two registered nurses or a physician and a nurse should be physically present form the beginning of the procedure till the end Stored in a double locked cupboard 2 senior nurses will carry each keys at all times A narcotic incident report form shall be filled by the involved Nurse/physician and signed by a witness, Nursing supervisor, Director-Nursing, Hospital Director and Head of pharmacy section. After completion white and pink copies of narcotic incident report form shall be retained in the pharmacy. Yellow copy shall be retained in the ward.

YES

NO

REMARKS

47

Who can administer narcotics? What is the process?

48 49

How do you store narcotic drugs? Who is responsible to carry the keys

50

What do you do if a narcotic is missing or broken or loaded but not used due to change in order/or patients condition? (What is the process in case of a narcotic drug incident?)

51 52

Yes, on the File Net Pharmacy room is kept locked How do you secure or control the flow to the pharmacy room always and only authorized people can enter What is the accepted temperature of refrigerator to store 2 - 8 degrees Celsius medicines and vaccines?

Do you have a policy?

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53 54

QUESTIONS
What is the cold chain for vaccines during transportation and handling? What do you do with expired medications?

EXPECTED ANSWERS
2 - 8 degrees Celsius Send to pharmacy who will send to CSC stores for destruction Near expiry medicines are those expected to expire within the next six months. Yes In Nursing units the narcotics shall be kept in double locked narcotic cabinets with provision of two set of keys; first set of keys shall be kept with 2 senior nurses in the unit and the second set of keys shall be in the custody of the security services in a sealed envelop labeled clearly ward number to which the key belongs and stored in a secure place. A log book shall be maintained for this purpose. Automatic stop order is the process of discontinuing a medicine when the pre-set duration has ended. Within one hour after the use.

YES

NO

REMARKS

555 Definition of near expiry medicines? Do you have a policy for control of medication sample and handling near expiry medications?

56

57

What is the process of storing the narcotic medications in Nursing unit?

58 59

Define the term Automatic stop Order? How often crash trolley medications should be replaced

PFE (Patient Family education) S. #

1 2 3 4 5 6 7 8 9

QUESTIONS
Which population is eligible to receive PFE in RH? Who is authorized to provide PFE in RH? Do you provide education to your patients about their care based on their learning assessment Who is responsible to identify patients & families educational needs Who is responsible to assess & identify patients who need clinical nutritional referral Who is responsible to educate the patient and family about safe and effective use of medical equipment Who is responsible to reassess the patients knowledge and understanding about safe and effective use of medical equipment Do you have any document to record patient and family education given? What are the common learning style to provide PFE

EXPECTED ANSWERS
All patients and families receiving care at RH All health care providers & Administrative staff who come in direct contact with patients Yes All healthcare providers Physician/Nurses Nurse/Healthcare provider Nurse/Healthcare provider Yes, Interdisciplinary health education record form Lecture, Demonstration and return demonstration, discussion, brochures, pamphlets, handouts, (reading materials)

YES NO

REMARKS

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10

QUESTIONS
Do you have any health education material available in the unit?

EXPECTED ANSWERS
Yes, available on file net Impaired vision ,Impaired hearing, Emotional barriers, Illiteracy ,Language barrier, Impaired speech, cultural /religious practices, lack of motivation etc. Back side of Interdisciplinary health education record form By making use of interpreters, we have a list of healthcare professionals with telephone numbers who could be contacted any time yes Suitable language, sufficient interaction among the patient / family and staff for effective learning, Patient/family preferences MRP Yes, Physician/Nurse/Social workers/Case Management/unit staff Physician/ nurses, pharmacists The patient and family are educated about safe and effective use of medical equipment. Concerned healthcare providers

YES NO

REMARKS

11 What are the learning barriers encountered? Where can we find the abbreviations used to 12 document in Interdisciplinary Health education Record form 13 How do you resolve language barrier? Do you have any system in process?

Is it included in the initial nursing assessment to 14 assess the patient for present allergies to food & medication 15 What are the Important things to consider while selecting teaching learning style

Who is responsible to explain to the patient / family 16 about complications of disease , procedure/treatment Is the patient and family are educated about 17 community resources available and who is responsible? 18 Who is responsible to educate the patient and family about safe and effective use of medication

What steps are undertaken if a patient has to 19 continue to use medical equipment at home after discharge? Who is responsible/

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QUESTIONS

EXPECTED ANSWERS
Yes, we have a format called Interdisciplinary health education record. Yes I will give you a copy

YES NO

REMARKS

Are patients learning needs assessed and 20 documented? Do you have any special format for documentation if so can I have a look at it? Do your patients/relatives receive education/information about all aspects of informed 21 consent? If so who is responsible to give that information? 22 Do you have access to a list of all available community resources for Health promotion and disease prevention including post discharge care? Can you provide me a list of community resources and can you tell me where it is available

Yes, MRP

Yes. Access the File Net under JCI standard "PFR" Yajeeco International Artificial Limbs, Medical Equipments & Rehabilitation Kim Salemaven 050-8055636 Procare Services for elderly/disabled in their own homes Tel. No. 04-2734346 Fax No. 04-2734348 pace_uae@emirates.net.ae Arab-Euro Home Nursing Compassionate nursing care & rehabilitation to the disabled, elderly or terminally in their own homes Tel. No. 04-2246146 Fax No. 04-2243558 info@aehomenurse.com Enaya Nursing at Home Home Nursing and Family Health Care Tel. No. 04-3455573, 04-3458880 Fax No. 04-3455270 Dynamic Rehabilitation Center Rehabilitation & Medical Equipment Tel. No. 06-5733995 dynamich@emirates.net.ae Hyperbaric Chamber Available at Dubai Hospital and Jebel Ali Dive Center

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QUESTIONS

EXPECTED ANSWERS
Transport Services for the deceased patients from the hospital Transport services for the deceased patients from the hospital. Between 0600 hrs 2100 hrs Shoeib Abdullah Tel. No. 04-2643355 Fax No. 04-2646741 Marhaba Services Airport escort services (arrival & departure) Tel. No. 04-2245664 Fax No. 2245780, 2062630 www.marhabaservices.com Dubai Wheel Chair Taxi Wheel Chair Taxi Tel. No. 04-2080808 Emergency use 04-2245331 Multiple Sclerosis Support Group For patients, family and friends suffering from MS Tel. No. 04-3953939 (Dubai) 03-7095292, 03-7615668 (Al Ain) Alcoholics Anonymous For Alcoholics and their families support group Help Line 050-6974393, 050-4143042, 04-3949398 alanoninuae@yahoo.com Rochester Wellness Clinic Cardiac Rehabilitation Clinic Tel. No. 04-3354824, 04-3354825 Fax No. 04-3354826 www.rochesterwellness.com info@rochesterwellness.com Mohameed Bin Rashid Al Maktoum Charity and Humanitarian Establishment Financial aid for treatment (UAE Nationals and residents) Tel. No. 04-2278777 Fax No. 04-2276777

YES NO

REMARKS

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QUESTIONS

EXPECTED ANSWERS
Handicapped Guardians association Social services for handicapped preserving rights for handicapped Tel. No. 06-5564222 Fax No. 06-5564499 Home Health Care Teams Providing free home health care (medical & nursing) for UAE nationals Al Towar HC Team 04-2612114 Al Mamzar HC Team 04-2967770 Al Safa HC Team 04-3943468 Teams in catchments area Special Family Support Meet the recreational needs of children with special needs Ms. Neena Mobile No. 050-7842488 Valley of Love Humanitarian services, counseling, social and financial services rendered Mr. Joseph Bobby (coordinator) Mobile No. 050-4548995 Mr. Mathew 0507289317 Mr. Govind Rao 0504949931 Light House Club Financial support for treatment larissamclaughlin@hotmail.com Mobile No: - 0509547599 Yasmin Financial support for treatment, arranges rehab materials/equipment and placement of patients back in their country, out pass for Pakistani patients without passport Mobile No: 050-4748029 Karuthal Arranges Rehab equipment, Financial support Mobile No: Johny John ( 050-6251068)

YES NO

REMARKS

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QUESTIONS

EXPECTED ANSWERS
Dubai Foundation for Women and Children Helpline 800111 (www.dfwac.ae).

YES NO

REMARKS

23 Do you access these resources when it is required? 24 What are the components included the in The Patient & Family Education?

Not directly but coordinate with Case management for accessing and arranging. Disease process and management Safe use of medications Safe use of Medical equipment Potential Interactions between medications and food Nutritional guidance Responsibilities of patients in their care, discharge instruction of continuing care Rehabilitation Techniques Informed consent Details are available on the Interdisciplinary health education record form) Yes, and I can access from the File Net. Yes Most common languages are Arabic, English, Urdu, Hindi, Malayalam Yes , have a list of interpreters available in each unit and also with telephone operator Yes. It is documented in the Interdisciplinary health education record form

Do you have education brochures / leaflets in place 25 for distribution? Do you know how to access them from the file net? While providing education do you take into 26 consideration Patients specific values & culture? What are the different languages, the Learning / 27 education is imparted in? Do you know how to access the list of interpreters of the hospital? Do you provide continuous education to patients and their family according to their health care 28 needs? Can you provide any evidence for continuing education?

PFR (Patient and Family Rights) S. #

1

QUESTIONS
Did you receive necessary training /education to ensure the implementation of PFR? Do you understand your responsibilities in protecting patients rights? Yes

EXPECTED ANSWERS

YES

NO

REMARKS

Yes. All patients will receive a copy of DOHMS official bill of Patient & Family Rights and responsibilities. Furthermore, it is displayed in DHA website and in clear areas of all DHA facilities. Yes. Nurse shall ask the patient if he has any special requirements related to his personal values and beliefs as a part of initial assessment process. This data will be recorded in the assessment form kept in the patients file. Nurse shall convey the information to concerned department regarding any matter related to patients Values and Beliefs as needed (Kitchen & Meals, Dressing, Religious & Spiritual Mattersetc)

Do you identify & respect patients values & beliefs? How?

Do you have a process in place, for spiritual/religious guidance/counseling Yes requests, when there is a need from patients?

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QUESTIONS

EXPECTED ANSWERS
Speak in a low tone. If the patient is in a single-bedded room knock before entering the room Draw the curtain if the patient is in a multi-bedded room Expose only the area to be examined or procedure to be preformed If patient is in the consultation room the door should be kept closed, Curtain should be drawn. Persons who are not involved in the treatment of the patients should not be present, unless authorized by patient. Nurse should be present when doctors gender is opposite than the patients. Cover the patient properly during transportation.

YES

NO

REMARKS

Do you have a policy /process in place for safeguarding patient's personal belongings and valuables? What about Yes special circumstances, like comatose patients? Can you explain the process? 6 Patient is for admission his/her personal valuables are registered in Patients Valuable Clearance Form and handed over personal belongings and valuables? to relatives / significant others. It is duly signed by relatives What about special circumstances, like /significant others, nurse. If security supervisor is present then comatose patients? Can you explain he will be second witness, but if not present, then another staff the process? nurse can be second witness. Policy is under revision by security office as process is slightly different now. Do your staff members understand their role in protecting patient &family rights? Do you have any special process to protect the vulnerable groups of Patients e.g. Psychiatric, Geriatric and Pediatrics. Yes

Yes, policy available on File Net

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9

QUESTIONS
Do you take special precautions to protect this identified group of vulnerable patients? Is confidentiality of patient health information maintained? Do you have any policy or process Are patients informed about alternatives to treatment and care? Do you consider patients needs related to pain? Do you assess & manage pain as appropriate? Do you assess & recognize dying patients unique needs? Do your patients receive information about their specific condition, as well as proposed treatment? Do your patients receive information when they are undergoing a planned procedure? Are they aware of who is authorized to perform the procedure? Do you obtain General consent from all patients visiting the hospital (ER, OPD, Admission office)? Are the patients &families informed of the scope of such general consents? Yes

EXPECTED ANSWERS

YES

NO

REMARKS

10 11 12 13 14

Yes, on File Net Yes Yes, (policy available on file net) Yes Yes

15

Yes

16

General Consent only taken for admitted patients through ED and OPD Before the following procedures : Surgical/Invasive procedures Anesthesia Utilization of blood &blood products High risk procedures & treatments Yes

17

What are the occasions you (physician) obtain Informed consent? Are you aware about the list of procedures / treatments that require informed consent?

18

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19 20

QUESTIONS
Can patient refuse hospitalization? What is the process in place How the organization does take measures to protect patients possessions from theft or loss? When information related to patients right is given do you use translators?

EXPECTED ANSWERS
Yes, DAMA form has to be completed before leaving the hospital Policy available on file net (Valuables policy under review) Yes, (list of translators with phone numbers available with operator and contact names list in each unit) Patients records are kept accessible for treating team. If the patient is not in a single-bedded room and when confidential subject is discussed; take the patient/family to a separate private area. Any discussion regarding patients care should not be done in public areas or in the presence of individuals that are not concerned. Patients record should be kept with the escorting staff to prevent loss and mishandling during transportation. Prior consent from patient/family needs to be taken when photographing/ videotaping patient's and patient's body parts.

YES

NO

REMARKS

21

23

How do you prevent disclosure of patient information

24 25

Do you have a process in place to deal Yes (Policy on File Net) with patients complaints Do you have any process for Do not No. resuscitate

SQE (Staff Qualification and Education) S. #

1 2

QUESTIONS
What process in place for ensuring the staff is competent in administration of medication?

EXPECTED ANSWERS
Staff has to pass medication administration competency test prior to commencing administration

YES NO

REMARKS

Do you have a list of competencies for all your Yes, each staff has a separate file available in the staff and where is it available? unit they are assigned All new appointment staff on joining, annually and whenever there is a new competency is developed/reviewed/updated based on change in practice or performance issues Based on job description Yes, on the file net

How often competencies are performed?

4 5

On what basis do you develop competencies? Does each designation have job description? Where is it available?

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6 7 8

QUESTIONS
What is the process for conducting researches in your organization? Do you have a policy related to conducting research? What are the different types of competencies in your organization

EXPECTED ANSWERS
Proposals are to be approved by DHA Research and Ethics Committee. Yes, available on the File Net Mandatory, generic, and unit based competencies O medication administration o infection control (including universal precautions)

YES NO

REMARKS

What are the mandatory competencies?

o basic life support o lifting and handling techniques o disaster response o care of patient receiving oxygen therapy o care of patient with tracheostomy

10

What are the generic competencies

o care of patient with indwelling catheter o care of patient with naso-gastric tube o perform a basic pain assessment

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QUESTIONS

EXPECTED ANSWERS
Which are relevant to an individual unit such as MRI / Psychiatry and include and not limited to: o demonstrated advanced airway management (ICU) o create and maintain a sterile field (OT) o care of client receiving ECT (Psychiatry) o interpret a cardiac rhythm strip All new staff members shall attend an Orientation Programme. Yes on the File Net

YES NO

REMARKS

11

What are the Unit specific competencies

12

What process in place for new staff members to adapt to new work and work place? Do you have any policy?

13

Do you have any documented evidence for the Yes, available in the staff file and a copy in the orientation program? unit of assignment