Pharmacist role NABH Accrefitation

Role of Pharmacists in NABH Accreditation

Compiled by Alok Bains

Pharmacists work closely with medical practitioners in hospitals to achieve hospital goals and public needs. They have important roles in each department of the hospital. But for NABH accreditation their main responsibilities are in the management of the medications.

 The hospital requires pharmacists as essential healthcare providers to push evidence-based medication and rational use of medicines. Irrational use of medication includes inadequate treatment, non-compliance with dose, self-medication, polypharmacy,  inappropriate medicines selection, etc. These lead to major health problems and waste of resources.

Management of Medications (MOM)

The pharmacists shall ensure the safe storage of drugs, checking of drugs' expiry date, documentation, dispensing of drugs on the prescription, proper administration of the drugs, availability of emergency medications, selection of high-risk medications, and verification of high-risk medications by appropriate persons. All the roles of pharmacists are governed by the written guidelines in the NABH Accreditation Standards.

Chapter 3 of the NABH Accreditation Standards for hospitals states eleven standards for the management of medications. Each standard has several objectives to be achieved by the pharmacists. The followings are standards and objectives to be achieved.

A) Standards: MOM 1

         Pharmacy services and usage of medication are done safely.

         Objective Elements

1. Commitment a:  Pharmacy services and medication usage are implemented following written guidance.

2. Commitment b: A multidisciplinary committee guides the formulation and implementation of pharmacy services and medication usage.

3. Excellence c: Mechanism to facilitate the multidisciplinary committee to monitor Literature reviews, information on medication management and update medication management processes.

4. Commitment d: A procedure to obtain medication when the pharmacy is closed.

5. Commitment e: Ensure uninterrupted and safe care by informing relevant staff about key changes in pharmacy services and medication usage.

B) Standard: MOM 2

The organisation develops, updates and implements a hospital formulary.

Objective Elements

1. CORE a. Multidisciplinary committee develops a list of medications appropriate for the patients.

2. Commitment b. A multidisciplinary committee reviews the list of medications at least annually.

3. Commitment c. Availability of current formulary for clinicians.

4. Excellence d. The clinicians adhere to the current formulary.

5. Commitment e. Adheres to the formulary medications.

6. Commitment f: Adheres to the procedure to obtain medications not listed in the formulary.

C) Standard: MOM 3

Medications are stored appropriately and are available where required

Objective elements

1. CORE a: Medicines storage in a clean, safe and secure environment following the manufacturer's recommendation(s).

2. Commitment b: Sound inventory control practices.

3. CORE c: Well-defined list of high-risk medication(s).

4. Achievement d: Storage of clinically necessary high-risk medications.

5. CORE e: Store separately high-risk, look-alike, sound-alike and different concentrations of medications. 

6. Commitment f. A Well-defined list of emergency medications and their storage..

7. CORE g: Emergency medications are available all the time.

D) Standard: MOM 4

Medications are prescribed safely and rationally.

Objective elements

1. Commitment a: Good practices/guidelines for the rational prescription of medications.

2. CORE: b: Adherence to the minimum requirements of a prescription

3. Commitment c: Drug allergies and previous ADR are considered before prescribing.

4. Excellence d: A mechanism to assist the clinician in prescribing medication

5. CORE e: Implementation of verbal orders to ensure safe medication management practices.

6. Achievement f: Audit of prescriptions to carry out safe and rational medications.

7. Achievements e: Audit recommendation implementations.

8. CORE h: Reconciliation of medications occurs at transition points of patient care.

E) Standard: MOM 5

Medication orders are written in a uniform manner.

Objective elements

1. Commitment a: Only authorised personnel write prescriptions.

2. Commitment b: Prescriptions reflect the patient's name and unique identification number, maintained in uniform medical records.

3. Commitment c: Legible, dated, timed and signed prescriptions.

4. Commitment d: Name of the medicine, route of administration, strength to be administered and frequency/time of administration on prescription.

E) Standard: MOM 6

Medications are dispensed in a safe manner.

Objective Elements

1. Commitment a: Safe dispensing of medications.

2. Commitment b: Recall medication effectively.

3. Commitment c: Near-expiry medications are handled effectively.

4. CORE d: Dispensed labelled medications. 

5. CORE e: Look at the return of medications.

6. Commitment f: Return of medications to the pharmacy is addressed.

E) Standard: MOM 7

Medications are administered safely.

Objective Elements

1. Commitment a: Medications are administered by those who are permitted by law to do so.

2. Commitment b. Label prepared medication before the preparation of a second drug.

3. Commitment c: The patient is identified before administration.

4. CORE d: Medication is verified from the medication order and physically inspected before administration.

5. Commitment e: Verify strength before administration.

6. Commitment f: Verify route before administration.

7. Commitment g: Vetify timing before administration.

8. CORE h: Measures to avoid catheter and tubing misconnections during medication administration are implemented.

9. Commitment i: Medication administration is documented.

10. Commitment j: Measures togovernpatient's self-administration of medications are implemented.

11. Commitment k: Measures to govern patients' medications brought from outside the organisation are implemented.

E) Standard: MOM 8

Patients are monitored after medication administration

Objective Elements

1. Commitment a: Patients are monitored after medication administration.

2. Commitment b: Medications are changed where appropriate based on the monitoring.

3. CORE c: The organisation captures near misses, medication or/and ADR

4. Commitment d: Report near misses, medication errors and ADR within a specified time frame.

5. Commitment f: Corrective and/or preventive action(s) are taken based on the analysis.

E) Standard: MOM 9

Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are used in a safe manner.

Objective Elements

1. Commitment a: Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are used safely.

2. Commitment b: Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are prescribed by appropriate caregivers.

3. Commitment c: Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents drugs are stored securely.

4. Commitment d: Chemotherapy and radioactive agents are prepared properly and safely and administered by qualified personnel.

5. Commitment e: A proper record is kept of the usage, administration and disposal of narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents.

E) Standard: MOM 10

Implantable prostheses and medical devices are used in accordance with the laid down criteria.

Objective Elements

1. Commitment a) Usage of the implantable prosthesis and medical devices is guided by scientific criteria for each item and national/international recognised guidelines/ approvals for such specific item(s).

2. Commitment b: Implements a mechanism for the usage of implantable prostheses and medical devices.

3. Commitment c: The patient and his/her family are counselled for the usage of the implantable prosthesis and medical device, including precautions if any.

4. Commitment d: The batch and the serial number of the implantable prosthesis and medical devices are recorded in the patient's medical record, the master logbook and the discharge summary.

5. Achievement: e. Recall of implantable prostheses and medical devices are handled effectively. 

E) Standard: MOM 11

Medical supplies and consumables are stored appropriately and are available where required.

Objective Elements

1. Commitment a: adherence to the defined process for the acquisition of medical supplies and consumables.

2. Commitment b: Medical supplies and consumables are used in a safe manner.

3. Commitment c: Medical supplies and consumables are stored in a clean, safe and secure environment; and incorporating the manufacturer's recommendation(s).

4. Commitment d: Sound inventory control practices guide the storage of medical supplies and consumables.

5. Commitment e: Mechanism to verify the condition of medical supplies and consumables.

   Compiled by Alok Bains