Introduction to Policy &
procedure
Presented by: Mahmoud Takkoush
Head of Nursing Department
Head of quality department in RHUH
BSN nursing
Master degree hospital administration
Outline
1.
2.
3.
4.
Definition of a process
Flowchart of medication use process
Format of policy and procedure
Policy and procedure of medication
administration
1. Definition of a process
A goal- directed, interrelated series of
actions, events, mechanisms or steps.
Process means every day work- the jobs
that you and your colleagues do and
are responsible for improving.
2.Flowchart medication use process
Selection
Procurement
Storage
Ordering &prescribing
Transcription
Distribution
Preparation
Dispensing
Administration
Documentation
Monitoring
3. Format of a policy &
procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Policy
Purpose
Scope of applicability
Responsibilities
Definitions & abbreviations
Related documents
Related records
Related tools/material/equipment/(if applicable)
Procedure
Flowchart
Reference
Diffusion
Policy
It is a predetermined course of action
established as a guide toward
accepted organizational strategies &
objectives
They are the guidelines on what needs to
be done.
Example
Policy:
Medication shall be administered by a qualified
registered nurse only upon a written
physician’s order.
Nurse students and orientees must be
supervised by a qualified registered nurse or
a credited university/school instructor when
preparing and administering medications.
Procedure
A method by which a policy can be
accomplished. It provides the instructions to
carry put a policy statement
Procedures are expressed as a series of
operational activities or series of steps that
should executed. They are written in a
directional fashion to achieve a desired
objective. It indicates “ the how “policies
should be implemented
4. Medication administration
policy & procedure
1. Policy:
- Medication shall be administered by a qualified registered nurse only upon a WRITTEN physician’s order.
- Nurse students and orientees must be supervised by a qualified registered nurse or a credited
university/school instructor when preparing and administering medications.
2. Purpose:
- To provide uniform guidelines for safe preparation, administration and documentation of medications.
- To ensure adequate patient monitoring and detection of occurring undesirable side effects following
medication administration.
3. Scope and Applicability:
This policy applies to all qualified registered nurses, midwives and adequately supervised students/
orientees, in all inpatient and outpatient units, for all physician ordered medications.
4. Responsibilities:
- All qualified registered nurses, midwives, and adequately supervised nursing students, orientees are
responsible for:
o Assessing the patient’s need for medications, their indications and contraindications.
o Being knowledgeable about medications contraindications, side effects and antidotes (when applicable).
o Verifying adequacy and completeness of physicians’ medication orders.
o Preparing the resources and the patient for administering medications.
o Administering medications to the patients properly and safely.
o Documenting and charging administered medications.
- All the credited physicians and residents are responsible for providing safe,
clear and complete medication orders as per Medical Documentation Policy
(MS-P-001)
5. Definitions and abbreviations:
- Contemporaneous: the quality of what is done during the same period of time; contemporaneous
documentation of an event is done as soon as the event occurs.
- Front Office: electronic application permitting creation of patient account upon admission, patient
demographic and medical history data entry, management of transfers and discharges, medical
supply and medication requests, diet order entry and nutrition management, inventory management
and billing among many other modules.
- Stationery: writing materials such as pens, pencils, paper and envelopes.
- IV: Intravenous
- MAR : medication administration record
- MRM : medical record manager, the brand name of the RHUH's electronic
medical record manager, an application permitting secure and editing and safe
storage of the patients electronic medical records.
- MW: midwives
- RN: registered nurse
- RHUH: Rafik Hariri University Hospital.
6. Related documents:
- Administration of high alert or dangerous medications policy CN-P-004
- Declaration of patient with allergy policy CN-P-002
- Patient identification policy CN.P.003
- Hand hygiene policy IC-P-001
- Usage of personal protective equipment IC-P-004
- Undesirable event procedure (incident accident) QS-P-004
- Medical Record Documentation MS-P-001
- Automatic stop order policy PH-P-002
7. Related records:
- Medication administration record CN-R-001
- Undesirable event record (Incident accident record) QS-R-014
- Broken drug sheet PH-R-031
- Against medical advice sheet AOS-R-011
- List of controlled drugs PH-L-013
- List of restricted antibiotics PH-L-016
- List of antidotes PH-L-017
- List of high alert or dangerous medications PH-L-018
- List of soundalike medications PH-L-019
- List of lookalike medications PH-L-020
- Medical order sheet or module on the MRM
- Charging, dispensing and scrapping modules on the front office application
- Consultation form on the MRM. Antimicrobial stability list
8. Related equipments and materials:
- Stationery and patients charts
- Computer system with access to MRM and Front Office applications
- Medication cart
- Clean medication tray, kidney basin, sharp container
- Medical supplies (medication cups, syringes, IV bags and tubings…)
- Hydro-alcoholic antiseptic hand solution.
- Disinfection liquid
- Sterile gauze
- Underpad
- Universal precaution equipment when required.
9. Procedure:
A. Patient Assessment
The RN or MW is to:
- Assess the patient for indication and contraindication for patient taking
medication.
- Check the patient’s vital signs
- Review the patient’s medical history, history of allergies (and presence of allergy band), medication and
diet history, and laboratory findings that may influence medication administration.
- Review current medications and identify possible interactions or incompatibilities.
- Assess patient’s knowledge regarding medication usage, its indications and side effects.
B. Order verification
The RN or MW is to:
- Check the accuracy, completeness and correct transcription of each patient’s MAR against the
corresponding prescribing physician’s written medication orders which should include the
medication’s name, dosage, administration route and frequency.
- Make sure that the physician’s medication order is well written under “medication” type and not “other” in
the MRM order module.
- Perform frequent checking of the MRM’s main screen for new medication orders in order to execute them
directly.
- Obtain medication order renewal from patient’s physician for the extended use drugs. (Ref: automatic stop
order policy PH-P-002)
- Make sure that the restricted medication orders are associated with the adequate physician consultation
form of the corresponding medical team.
- Obtain renew orders from consulting physician when restricted medication
orders are outdated. (Refer to list of restricted antibiotics PH-L-016).
C. Preparation
The RN or MW is to:
- Perform hand hygiene.
- Assure good lighting and absence of distractions and interruptions.
- Unlock the medication cart.
- Prepare the medications for one patient at a time. Keep all the pages of one patient’s chart together.
- Select the correct medication from the patient’s medication drawer or the floor’s stock supply.
- Be aware of medications lookalike and sound-alike.
- Calculate medication dose as necessary.
- Check the medications’ expiration dates, stability, consistency, discoloration and compatibility with other
medications.
- Label the medications with the patient’s name, room number, medication name, dose, route, date and time of
administration. Sign the prepared medication’s label with initials.
- Compare record with the prepared medications.
- Return unused medications to patient’s drawer and read their labels again.
Refrigerate diluted or opened solutions as recommended.
DO NOT LEAVE MEDICATIONS UNATTENDED and unlabelled.
Carefully review MAR to ensure the “FIVE RIGHTS”:

Right patient

Right medication

Right dose

Right route

Right time.
-
Check three times the medication label:

When reaching for the container or the unit dose package

Immediately before pouring or opening the medication

When replacing the container to the drawer or shelf or before giving

the medication to the patient.
D. Medications administration
The RN or MW is to:
- Take the correct medication to the correct patient at the correct prescribed time (allowed timeframe for
medication administration is 30 minutes prior or after their scheduled timing).
- Identify the correct patient by comparing full name on MAR with name on patient’s identification bracelet and
ask the patient to state his name (if well oriented).
- Explain to patient or his family the purpose, intended effect and side effect of each new medication before
administering it and reply to the patient’s questions about the medication.
- Assist the patient to sitting position if possible.
- Administer medication properly.
- Stay at the patient’s bedside until he has taken ALL of his/her medications.
- Assist the patient in returning to a comfortable position.
- Dispose of soiled supplies properly.
- Perform hand hygiene after administration of medications.
E. Documentation (refer to Nursing Documentation Policy MC-P-001)
The RN or MW is to:
- Record the administered medications on the MAR contemporaneously and sign initials and full name (taking into
consideration countersigning of high alert medications).
- Document withheld and omitted medications and clearly specify the reason in case of omission on the MAR.
F. Charging
The RN or MW is to:
- Charge the medications that were used from the unit’s stock supply on the Front Office’s medication dispensing
module.
- Return the unused or discontinued medications both physically to the pharmacy and on the computerized Front
Office’s drug return module.
- Unwrapped or opened medications shall not be returned and must be discarded properly.
The unit’s responsible nurse is to:
Scrap the broken or flawed medications physically and through the Front Office’s scrap module. If a
medication vial is broken fill a broken drug sheet and an incident report form.
G. Patient monitoring
The RN or MW is to:
- Reassess the patient within 30 minutes after medication administration and evaluate response.
- Notify physician if the patient develops undesirable reaction and report adequately on incident accident report or
adverse event report according to the observed reaction.
H. Special consideration
The RN or MW is to:
- Urge the physician to document verbal orders. Verbal orders are only permissible in emergency cases; these
must be written as soon as the emergency status is over. (Refer to Medical record documentation MS-P001).
- Inform the head of the unit and the attending physician if a patient refuses to take his medications and
document it on the MAR, the nursing progress note, fill against medical advice sheet, and an incident
report if the patient develops adverse event.
- Ensure the presence of a second RN who calculates and countersigns the
documentation administration of high alert drug.
10. Flowchart
11. References:
- Potter, Perry. (2001) Fundamentals of
Nursing, 5th edition, p.20-22, Mosby.
- Elkin, Perry, Potter. Nursing Interventions &
Clinical Skills, 3rd edition,
Mosby.
- Taylor, Lillis, Le Mone. Fundamentals of
Nursing, Lippincott Williams &
Wilkins, 5th Edition.
12. Diffusion:
Thanks
For
Your
Active
Listening