Pharmaceutical Care P&P 2019.Pdf
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AL TICAL CA UTIC CA CEU RE E RE A C M PO A P R L M O A IC R L I H Y A C P H Y P M S OH IT Sultanate of Oman HEALTH UN Ministry of Health MOH HEALTH UNITS TICAL C EU ARE AC P M O R L CEUTICA A IC A L H Y M C P R A A R H E P P O S E L R IC U IES ED M S & PROC OH IT HEALTH UN 1ST EDITION JAN. 2019 Directorate General of Medical Supplies Certified since February 2011 Sultanate of Oman Ministry of Health Pharmaceutical Care Policies & Procedures in MOH Health Units 1st Edition Jan. 2019 His Majesty Sultan Qaboos Bin Said MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES 4 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES TABLE OF CONTENTS Sr Contents Page No 1 Preface 7 2 Introduction 8 3 Acknowledgment 9 4 Approval Process 10 5 Acronyms 11 6 Pharmaceutical Care Policies & Procedures P&P/001 • Pharmaceutical care Scope of Services 13 P&P/002 • Pharmacy Staff Orientation Policy 18 P&P/003 • Pharmacy Professional Development 22 P&P/004 • Pharmacy Staff Competency Assessment 27 P&P/005 • Pharmacy Departmental Meetings 31 P&P/006 • Pharmacy Departmental Safety Policy 35 P&P/007 • Pharmacy Emergency Preparedness and Response Plan 42 P&P/008 • Pharmacy Duty Rostering Policy 49 P&P/009 • Pharmacy Quality Management System 52 P&P/010 • Drug Information Services 72 P&P/011 • Procurement of Medical Supplies 77 P&P/012 • Managing Medical Supplies 83 P&P/013 • Response to Out-of-Stock Formulary Medications 96 P&P/014 • Medications Returned by Patients 99 P&P/015 • Floor Stock Medication Guidelines 103 P&P/016 • Patient’s Own Medications 106 P&P/017 • Medication Reconciliation Policy 110 P&P/018 • Medication Order Review 113 P&P/019 • When required (PRN) Medications 117 5 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES Sr Contents Page No P&P/020 • Discharge Medication Order 119 P&P/021 • Medication Dispensing Guidelines 122 P&P/022 • Patient Counselling 132 P&P/023 • Unit Dose Dispensing System 137 P&P/024 • Drug Utilization Review 143 P&P/025 • Drug and Therapeutics committees 148 P&P/026 • Off Label Use of Medications 157 P&P/027 • Restricted Formulary Medications 160 P&P/028 • Handling of Non-Formulary requests 163 P&P/029 • Emergency Crash Cart Medications 168 P&P/030 • Handling Patient Drug Allergy 172 P&P/031 • Drug - Food Interactions 175 P&P/032 • Drug - Drug Interactions 183 P&P/033 • Management of Adverse Drug Reactions 190 P&P/034 • Medication Error Reporting 197 P&P/035 • High Alert Medications 203 P&P/036 • Look-Alike/ Sound-Alike Medications 211 P&P/037 • Handling Hazardous Medicines 216 P&P/038 • Handling Drug Recalls 226 P&P/039 • Extemporaneous Pharmaceutical Preparations 231 P&P/040 • Compounding Sterile Preparations 236 P&P/041 • Total Parenteral Nutrition preparations 244 P&P/042 • Compounding of Bevacizumab For Ophthalmic Use 249 P&P/043 • Drug Quality Reporting Program 255 P&P/044 • Medical Devices Quality Reporting 260 P&P/045 • Medical Representative Visits 266 6 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES PREFACE Pharmaceutical Care is vital for the achievement of the intended medical outcomes which ultimately is envisaged to improve the quality of life of patients. The important role of pharmacists in managing drug therapy accentuate a need for an efficient and continuous pharmacy professional development programs to further heighten their qualifications, skills, and competence. The strategic Human Resources Planning trend for Pharmacy profession in MOH has shown a remarkable success in the past years through influencing pharmacy career path with a particular focus on specialization in clinical pharmacy and continual upgrading of the status of assistant pharmacists holder of pharmacy diploma to an advanced bachelor in pharmacy. In 2015 the Ministry clearly defined the specialties and responsibilities of various pharmaceutical care departments. This effort has been boosted further with the establishment of a department earmarked for Pharmaceutical Care in (DGMS) with an aim to empower, support, and integrate the professional practice of pharmaceutical care across the health care system in line with the international standards. Having standardized operational pharmaceutical care policies and procedures in place ensure that the pharmacy professionals in the Ministry of Health follow an approved and unified standards of practice, and are expected to promote efficiency, effectiveness, and consistency. Concomitantly, this manual serves as a guide for the pharmaceutical care providers to enhance the quality of their day-to-day tasks, and to act as catalyst for the spread of good practices that ensure safe and well-informed therapy for the patients. I hope that this manual proves its worth and importance as an indispensable guide to practitioners in the constitutive domain of pharmaceutical care and is able to add to the body of knowledge of health care management in general. Dr. Darwish Bin Saif Al Maharbi The Under Secretary for Administration and Finance 7 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES INTRODUCTION As per the Pharmaceutical Care Department Strategy Execution Plan 2017-2020, I am pleased to enclose herewith the Pharmaceutical Care Policies & Procedures Manual - 2018 intended for the internal use by the Pharmaceutical care providers in MOH Healthcare units as a tool to help individuals accomplish their work within each institution and to facilitate decision-making, with the aims of ensuring appropriate consistency and serve as a guide and educational informative reference as well. This manual describes standardized 45 policies and procedures based on most functions that all Pharmacists and Assistant Pharmacists should perform for individual patient care in organized health systems. The use of these policies would foster consistency in the provision of pharmaceutical care and support continuity of care within a practice setting. Further, a standardized method would establish consistent documentation so that patient-specific and medication-related information could be shared between pharmacy staff and among other health care professionals in various healthcare units. These policies and guidelines are carefully developed based on the available resources in the Ministry and are best tailored from the related pharmaceutical care guidelines established by WHO, FIP, FDA, NHS, MHRA, ASHP, ACCP, APhA, ISMP, NICE, NIOSH, NCBI and other international guidelines on pharmacy practice from Health authorities in Australia, Canada, Malaysia etc. Further, they had been shared with the Pharmaceutical care service providers in Regional Hospitals and Departments of Pharmacy and Medical Stores in the Governorates in the Ministry of Health and accordingly, the valuable feedback and inputs received are incorporated in this manual as needed. Through our many years working without standard pharmaceutical care policies and procedures, it has become clear to us that it is of utmost important and it is the right time to have a unified standardized guidelines to provide clarity when dealing with issues and activities that are critical to health and patients safety. This first edition of Pharmaceutical care Manual is considered as the starting point, aiming to bring together all necessary policies and procedures which has been written in response to a need to develop and generate a safe and efficient standing pharmaceutical care at all levels in the Ministry. The content of this manual will be kept under review as more experience is gained and practical information is obtained on fundamental professional responsibilities and advanced pharmacy practice. Ph. Nussaiba Habib Mohammed, Director General of Medical Supplies 8 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES ACKNOWLEDGEMENT The Ministry of Health represented by the Directorate General of Medical Supplies is very grateful and expresses great appreciation and thanks to the following pharmacy professionals for their genuine efforts in bringing out this valuable manual: • Sr.Ph. Hassan Ali Mohd., Quality Management & Medicine Safety Section • Sp.Ph. Sara Al Balushi, Director, Pharmaceutical Care Dept. • Ph. Sumaiyya Al Zaabi, Hospital Pharmaceutical Care Section • Ph. Wala Ahmed Atout, Hospital Pharmaceutical Care Section • Ph. Noura Al Shabibi, PHC Pharmaceutical Care Section • Ph. Maiya Al Mawaali, PHC Pharmaceutical Care Section Gratitude is extended also to the following Pharmaceutical care service providers in MOH Health Units for their valuable comments and feedback: • Pharmaceutical Care & Med Stores Dept., Sultan Qaboos Hospital-Salalah • Pharmaceutical Care & Med Stores Dept., Al Nahdha Hospital • Pharmaceutical Care & Med Stores Dept., Nizwa Hospital • Pharmaceutical Care & Med Stores Dept., Sohar Hospital • Pharmaceutical Care & Med Stores Dept., Sur Hospital • Pharmaceutical Care & Med Stores Dept., Ibra Hospital • Pharmaceutical Care & Med Stores Dept., Khasab Hospital • Pharmaceutical Care & Med Stores Dept., Ibri Hospital • Pharmaceutical Care & Med Stores Dept., Al Buraimi Hospital • Pharmaceutical Care & Med Stores Dept., Rustaq Hospital • Pharmacy & Med Stores Dept. – DGHS, Dhofar Governorate • Pharmacy & Med Stores Dept. – DGHS, Muscat Governorate • Pharmacy & Med Stores Dept. – DGHS, Al Wosta Governorate • Pharmacy & Med Stores Dept. – DGHS, North Sharqiya Governorate • Pharmacy & Med Stores Dept. – DGHS, South Sharqiya Governorate 9 MOH PHARMACEUTICAL CARE POLICIES & PROCEDURES APPROVAL PROCESS Name Title Quality Management & Medicine Sr.Ph. Hassan Ali Mohd. Safety, DGMS Written by Sp.Ph. Sara Al Balushi Director, Pharmaceutical Care, DGMS Clinical Pharmacist, Hospital