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Chapter Name: MOM
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MOM Quality Manual
Chapter-III
Management of
Medication (MOM)
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Quality Manager Chief Executive Officer Operations Head
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Chapter Name: MOM
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Original and Master copy. Any hardcopy, printed or photocopied, is considered an uncontrolled copy, unless it is
the original, signed-off version.
Apollo Clinic (A Licensee of Sanjeevani Health and Lifestyle
Private Limited)
The Galleria, 1B, Street Number 124, BG Block, Action Area- I, New Town, Kolkata, West Bengal, 700156
Issue Date: 01.06.2024
Version / Issue No.: 01
Next date of revision: 01.06.2025
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Approved By: Administrator :
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Publication, reproduction, photocopying, storage, or transmission electronically or otherwise, of all or any part
of these documents without the prior written permission from Apollo Clinic (New Town) is strictly prohibited. It
is illegal to make copies of all or any part of these documents (whether internally or externally) without the
prior written permission of the owner of the document. For permission regarding the use of all or any part of
the documents, contact Apollo Clinic (New Town).
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Chapter Name: MOM
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Amendment Record
Sl. Page Clause Date of Amendment Sign of Head-
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Chapter Name: MOM
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MOM.1. The clinic develops, updates and implements a formulary.
a. A list of medications appropriate for patients as per the scope of the clinical services is
developed collaboratively by a multi-disciplinary committee.
At CAN there is a multidisciplinary committee to look into the medication management. The committee is
headed by a clinician specialized in general medicine. The roles and responsibilities of the members are
properly defined, which includes but not limited to developing medication management processes,
developing and revising the clinic's formulary, evaluating medication and material use and patient safety
incidents involving medications. The committee prepared the clinic formulary. The formulary includes
medications necessary to meet the Clinic's mission, patient needs and scope of services. The formulary is
prepared keeping in mind the “National List of Essential Medicines” and “WHO Model List of Essential
Medicines”. The list of medications is based on national or international standards like WHO/ANSI\ADA\
ISO\CE. The clinic has prepared the specialty wise formulary. At a minimum, the formulary includes the
name of the molecule, formulation and strength(s). The clinic endeavors to limit the number of drug
concentrations of a particular drug in the formulary. The policy on formulary is defined & documented in
(ACN/MOM/ RD/02).
b. The current formulary is available for clinicians to refer to.
The current formulary is made available to all treating clinicians. The clinic ensures that clinicians have
access to the current version of the formulary. The formulary is made available in both physical or
electronic form.
c. Clinicians adhere to the current formulary.
The clinic ensures that the prescriptions are as per the formulary. ACN monitors the frequency of
prescriptions being rejected/ or which local purchase is done because it contained non-formulary drugs.
The committee do the root cause analysis and prescribe the corrective actions accordingly.
d. The clinic adheres to the written guidance for acquisition of formulary medications.
At ACN there is a written guidance addresses the issues of vendor selection, vendor evaluation, reorder
levels, indenting process, generation of the purchase order, and receipt of goods. The guidance also
addresses managing stock-outs due to various reasons. The policy on acquisition of formulary medications
is defined and documented in (ACN/MOM/ RD/03).
e. The clinic adheres to the procedure to obtain medications not listed in the formulary.
At ACN there is written guidance used to obtain medications not listed in the formulary. Whenever there is
a local purchase of medication that is not listed in the formulary, the clinic has a process of evaluation,
authorization and ratification and to decide on its subsequent inclusion in formulary if necessary. Local
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Chapter Name: MOM
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purchases is the procedure which is used to obtain medications not listed in the formulary to take care of
the immediate requirement.
MOM.2. Medications are stored appropriately and are available where required.
a. Medications are stored in a clean, safe and secure environment; and incorporating the
manufacturer's recommendation(s).
At ACN the medications are stored in a space which is clean, safe and secure. The clinic adheres to the
storage requirements of the drugs as specified by the manufacturers. In the absence of manufacturer's
instructions, the clinic developed and implemented storage requirements for these medications. Storage
requirements is applicable to all areas where medications are stored, including day care and in-house labs
respectively. Beyond expiry date drugs (before disposal), are stored separately and away from drugs/
material which are intended for patient use.
The medications are always stored in a organized manner. Overall cleanliness of the storage area is
maintained all the times.
Where appropriate, temperature monitoring of the room, the cold storage area/refrigerator is done at
least twice a day. In case of areas which are not open on all days, it is done on all working days.
Medications are kept protected from loss or theft. Some of the ways which are used is by ensuring limited
access to medication storage areas to authorized team members, locking medication carts and never
leaving them unattended, or storing medications in an area that is continuously staffed. To check for loss
or theft, the clinic conducts audits at regular intervals (as defined by the clinic) to verify the stock and
detect instances of loss or theft. The policy on medication storage is defined and documented in
(ACN/MOM/ RD/04).
b. Sound inventory control practices guide storage of the medications.
The Clinic follows sound inventory control practices like ABC, VED, FSN, First Expiry First Out, Lead Time
Analysis, etc. or a combination of these. Medicines are available at all times and are replenished promptly
when used. Adequate quantity of medications is stocked at all times. An inventory check is done at least
daily/weekly to ensure the same. Medicines are stored in an alphabetical order of their generic names. The
clinic also has a mechanism for handling medications which are not a part of the regular inventory. For
example, a physician's sample medications.
c. The clinic defines a list of high-risk medication(s).
High risk/high alert medications carry a heightened risk for adverse outcomes and catastrophic harm
whenever there is an error. High-risk medications/high alert medications include medicines with a low
therapeutic window, controlled substances, psychotherapeutic medications, look-alike and sound-alike
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Chapter Name: MOM
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medications, and concentrated electrolytes. At ACN there is a defined policy on high risk medication
management which is documented in (ACN/MOM/ RD/05).
d. High-risk medications are stored in areas of the clinic where it is clinically necessary.
High-risk medications are stored in pre-determined areas of the clinic. Clinical needs is determined to
ensure the availability of these drugs in such areas. In all such areas, safeguards is in place to prevent
inadvertent administration.
e. High-risk medications including look-alike, sound-alike medications and different
concentrations of the same medication are stored physically apart from each other.
AT ACN many drugs in ampoules, vials or tablets may appear similar (look- alike) or have similarly sounding
names (sound-alike). These drugs and material are identified periodically, and the Look-alike Sound-alike
medications (LASA) list is made available in all units where drugs are stored. Different concentrations of
the same drug are also identified. The list is developed from the formulary. The list is revised at regular
intervals depending on the changes in the formulary and changes in the packaging (in case of look-alike). A
good practice is to store the two identified look-alike/sound-alike drugs or different concentrations of the
same drugs as far apart physically as possible, say at opposite ends of the room. This is in addition to
regular storage practices.
f. The list of emergency medications is defined and is stored uniformly.
The list of emergency medications is prepared in consonance with sound clinical practices and
documented. Crash carts are used to store these medications in a standardized manner, i.e. the rows and
drawers has defined medicines. No other is kept stored with emergency medications.
g. Emergency medications are available at all times and are replenished promptly when used.
Adequate quantity of emergency medicines is stocked at all times. An inventory check is done at least daily
to ensure this.
MOM.2. Medications are prescribed safely and rationally.
a. Medication prescription is in consonance with good practices/guidelines for the rational
prescription of medications.
This addresses both out-patient and daycare prescription. The clinic shall ensure that the doctors are
trained/sensitized on the rational prescription of medications. WHO states: “Rational use of medicines
requires that patients receive medications appropriate to their clinical needs, in doses that meet their own
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Chapter Name: MOM
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individual requirements, for an adequate period of time, and at the lowest cost to them and their
community."
b. The clinic adheres to the determined minimum requirements of a prescription.
Prescriptions generated within the clinic (day care and OPD) adheres to national/international guidelines
and those of regulatory bodies. At a minimum, the prescription contains the name of the patient; unique
number; name of the drug (generic composition is mandatory except in the case of combinations of
vitamins and/or minerals), strength, dosage instruction, duration and total quantity of the medicine; name,
signature and registration number of the prescribing doctor. Only the designated medical officer(s) who is
permitted by the relevant regulatory authority is authorized to prescribe medications. Error-prone
abbreviations is not used. All prescriptions is written in capital letters. Prescription errors or illegible
prescriptions will be initialed after single strikethrough and rewritten. The policy on Prescription and
Dispensing of Medicines is documented in (ACN/MOM/RD/06).
c. Drug allergies and previous adverse drug reactions are ascertained before prescribing.
Drug allergy and previous adverse drug reaction is ascertained during the initial consultation or at any
point in time during care. It is a good practice to document drug allergies prominently in the medical
record, both in OP and day care.
d. The clinic has a mechanism to assist the clinician in prescribing appropriate medication.
The clinic provided its doctors a mechanism(s) to help identify drug interactions, food-drug interactions,
therapeutic duplication, dose adjustments etc. This is maintained in physical form.
e. High-risk medications including look-alike, sound-alike medications and different
concentrations of the same medication are stored physically apart from each other.
At ACN many drugs in ampoules, vials or tablet’s appearance is similar (look- alike) or have similarly
sounding names (sound-alike). These drugs and material are identified periodically, and the Look-alike
Sound-alike medications (LASA) list is made available in all units where drugs are stored. Different
concentrations of the same drug are also identified. The list is developed from the formulary. The list is
revised at regular intervals depending on the changes in the formulary and changes in the packaging (in
case of look-alike). The identified look-alike/sound-alike drugs or different concentrations of the same
drugs are stored as far apart physically as possible, by following criss cross method and also at opposite
ends of the room. This is done in addition to regular storage practices. The List of LASA drugs are defined
and documented in (ACN/MOM/RD/07).
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f. The list of emergency medications is defined and is stored uniformly.
The list of emergency medications is prepared in consonance with sound clinical practices and it is
documented. Crash carts are used at the clinic to store these medications in a standardized manner, i.e.
the rows and drawers have defined medicines. No other drugs are kept stored with emergency
medications. A daily checklist is also maintained to check the crash cart. The list of emergency drugs are
defined and documented in (ACN/MOM/RD/08).
g. Emergency medications are available at all times and are replenished promptly when used.
Adequate quantity of emergency medicines is stocked at all times. An inventory check is done on daily
basis to ensure this.
MOM.3. Medications are prescribed safely and rationally.
a. Medication prescription is in consonance with good practices/guidelines for the rational
prescription of medications.
This addresses both out-patient and daycare prescription. The clinic ensures that the doctors are
trained/sensitized on the rational prescription of medications. WHO states: “Rational use of medicines
requires that patients receive medications appropriate to their clinical needs, in doses that meet their own
individual requirements, for an adequate period of time, and at the lowest cost to them and their
community."
b. The clinic adheres to the determined minimum requirements of a prescription.
At ACN, the prescriptions consist the name of the patient, unique number, name of the drug (generic
composition is mandatory except in the case of combinations of vitamins and/or minerals), strength,
dosage instruction, duration and total quantity of the medicine, name, signature and registration number
of the prescribing doctor. Only the designated medical officer(s) who is permitted by the relevant
regulatory authority prescribes narcotics, Error-prone abbreviations not used. All prescriptions are written
in capital letters. Prescription errors or illegible prescriptions will be initialed after single strikethrough and
rewritten. As reference Drugs and Cosmetics Act and the Code of Medical Ethics is considered at all times.
The policy on prescription is defined & documented in (ACN/MOM/RD/09).
c. Drug allergies and previous adverse drug reactions are ascertained before prescribing.
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Drug allergy and previous adverse drug reaction are ascertained during the initial consultation or at any
point in time during care. It is also documented prominently in the medical record, both in OP and day
care.
d. The clinic has a mechanism to assist the clinician in prescribing appropriate medication.
The clinic has provided its doctors a mechanism(s) to help identify drug interactions, food-drug
interactions, therapeutic duplication, dose adjustments etc. This is done by electronic or physical form.
e. Written guidance governs implementation of verbal orders and ensures safe medication
management practices.
The clinic ensures safe medication management practices for verbal orders through written guidance and
implementation of the same. The written guidance mentioned who can give verbal orders, when can they
be given and how these orders will be authenticated. Verbal orders is limited to urgent situations where
immediate written or electronic communication is not practical. To the extent possible, their usage is
limited. The clinic has an approved list of formulary drugs which can be ordered verbally. It ensures that
the procedure incorporates good practices like “repeat back/read back”.
A verbal order is counter-signed by the doctor who ordered it within 24 hours of ordering.
The policy on verbal orders is defined & documented in (ACN/MOM/RD/10).
f. Audit of medication orders/prescription is carried out to check for safe and rational
prescription of medications.
At ACN regular audit is conducted to check the safe and rational prescription of medications.
The scope of the audit includes:
• Legibility, use of capitals in written orders
• The appropriateness of the drug, dose, frequency, and route of administration
• The presence of therapeutic duplication
• The possibility of drug interaction and measures taken to avoid the same
• The possibility of food-drug interaction and measures taken to avoid the same.
• The requirements of MOM.3.b. to h standard.
This is done at least once a month using a representative sample size.
It is done by the multidisciplinary committee.
g. Corrective and/or preventive action(s) is taken based on the audit, where appropriate.
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The records of the audit are documented and maintained. The findings are analyzed and suitable
corrective and/or preventive action(s) is taken based on the root-cause analysis.
h. Reconciliation of medications occurs at transition points patient care.
The purpose of reconciliation of medication is to ensure that the list of medication that a patient has to
receive is complete and up-to-date with past clinical conditions and present care plan. The prescribed
medications are checked for accuracy at the transition points, such as the time of entry in the clinic, It is
preferable that medication reconciliation also occurs after cross-consultation. Medication reconciliation is
documented.
MOM.4. Medications orders are written in a uniform manner.
a. The clinic ensures that only authorized personnel write orders.
At ACN medication orders are written by a doctor who at a minimum, holds a MBBS / BDS qualification.
b. Orders for medicines are written in a uniform location in the medical records, which also reflects
the patient's name and unique identification number.
Medication orders is written in capital letters only. In case abbreviations which are used, a list of approved
standardized abbreviations for medication orders is used throughout the clinic. Error-prone abbreviations
are not be used. For this the Institution for Safe Medication Practices guidelines are used as reference.
Medication orders contains the name of the medicine, route of administration, strength to be
administered and frequency/time of administration.
MOM.5. Medications are dispensed in a safe manner wherever applicable.
a. Dispensing of medications is done safely.
At ACN Written guidance is laid down for the dispensing of medications. Medications is dispensed only
against a valid prescription or medication order (except for over-the-counter drugs). The medications are
checked before dispensing. This includes a check of the generic composition, formulation, expiry date, and
where applicable the strength. Physicians' samples strictly not sold.
b. Medication recalls are handled effectively.
At ACN recall is done based on communication from regulatory authorities, manufacturers or internal
feedback. Recall procedure in response to internal feedback also includes providing information to the
appropriate regulatory authority. The policy on medication Recall is defined and documented in
(ACN/MOM/RD/11).
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c. Near-expiry medications are handled effectively.
The clinic could define as to what constitutes “near expiry”, for example, three months before the expiry
date. The clinic's mechanism ensures that near expiry drugs are withdrawn and that no beyond expiry date
medication is available.
d. Dispensed medications are labelled.
At ACN all the dispensed medications are labeled at a minimum, the label includes the dosage instruction
in a manner that the patient understands. Labelling is applicable only for out-patients. In instances when
medicines are dispensed either as cut strips or from bulk containers, the label must include the drug name,
strength, dosage instruction (in a manner that the patient understands) and expiry date. This is applicable
for both day care and out-patients.
e. High-risk medication orders are verified before dispensing.
At ACN High-risk medications are given only after written orders, and after verified by the staff before
dispensing. This shall adhere to statutory requirements where applicable.
MOM.6. Medications are administered safely.
a. Medications are administered by those who are permitted by law to do so.
At ACN only a registered nurse or doctor with a minimum of MBBS qualification can administer
medication. The policy on medicine admiration is defined and documented in (ACN/MOM/RD/12).
b. Prepared medication is labelled prior to preparation of a second drug.
At ACN labelling is done when more than one drug is prepared and loaded. This includes the patient name,
UHID, drug name, strength, dose, dilution, preparation date etc.
c. The patient is identified prior to administration.
At ACN at a minimum, two identifiers are used for identification with one of them being the unique
identification number and name.
d. Medication is verified from the prescription and physically inspected before administration.
Staff administering medications should verifies the medication order and ensures that medications are
administered appropriately. They also check the general appearance of the medication (e.g., melting,
clumping, etc.) and the expiry dates before administration. If any of the parameters concerning an order,
namely name, strength, route or frequency/time are missing or incomplete, administration of medication
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is deferred pending early verification by the treating team. In case the confirmation is obtained verbally, it
is considered a verbal order and the procedure for verbal orders is adhered.
In the case of high-risk medication(s), the verification is done by at least two staff (nurse-nurse or nurse-
doctor) independently and documented.
e. Strength, route and timing is verified from the order and medication administration is
documented.
At ACN, before administration, the person administering the drug verifies the strength from the
medication order. In case of discrepancy, medication administration is deferred. Where applicable, the site
of administration is also verified.
The organization ensures that the documentation of medication administration is done in a uniform
location. It includes the name of the medication, strength, route of administration, timing and the
name/employee ID number and signature of the person who has administered the medication. Medicines
administered are documented each time for each dose of the same medication separately.
MOM.7. Patients are monitored after medication administration.
a. Patients are monitored after medication administration.
At ACN relevant monitoring is done after medication administration collaboratively to verify that medicine
is having its intended effect. Medication administration is documented. Besides, this helps identify near
misses, medication errors and adverse drug reactions.
b. Medications are changed where appropriate based on the monitoring.
Medication changes are based on clinical response and adverse drug reactions if any.
c. The clinic captures near miss, medication error and adverse drug reaction.
At ACN near miss, medication error and adverse drug reaction are defined. This is in consonance with best
practices. The clinic has written guidance to direct the implementation of identifying, documenting,
reporting, analyzing and acting in response to a near miss, medication error and adverse drug reaction. The
policy on this is defined and documented in (ACN/MOM/RD/13).
d. Near misses, medication error and adverse drug reaction are reported within a specified time
frame.
The clinic has defined the timeframe for reporting once any of this has occurred and adhere to the same.
e. Near misses, medication errors and adverse drug reactions are collected and analyzed.
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At ACN details of near miss, medication error and adverse drug reaction incidents are collected and
analyzed by a multidisciplinary team, which includes the clinicians. The analysis is completed in a defined
time frame.
f. Corrective and/or preventive action(s) are taken based on the analysis.
At ACN where appropriate, corrective and/or preventive action are taken. The records of the same is also
maintained. The corrective and/or preventive action(s) is taken based on the root-cause analysis.
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