8/23/25, 1:01 PM NABH Hospital Accreditation
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MOM.1:MULTIDISCIPLINARY COMMITTEE GUIDES PHARMACY SERVICES AND MANAGEMENT OF MEDICATION.
System
Evidence
Compliance
Score
1. Is the organisation developing, updating, and implementing a list of medications appropriate for the patients and as per the scope of the organisation's clinical
services?
Systems are in place
Some evidence
61-80% compliance
2. Are pharmacy services and medication usage implemented following written guidance through a multidisciplinary committee?
Systems are in place
There is evidence
61-80% compliance
3. Does the organisation adhere to the procedure for the acquisition of formulary medications and medications not listed in the formulary?
Systems are in place
There is evidence
61-80% compliance
4. Is there a procedure to obtain medication when the pharmacy is closed?
Systems are in place
There is evidence
61-80% compliance
5. Are the implantable prostheses and medical devices used in accordance with the laid down criteria?
Systems are in place
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There is evidence
61-80% compliance
6. Are the clinicians adhering to the current formulary?
Systems are partially in place
There is evidence
61-80% compliance
[Link] ARE STORED APPROPRIATELY AND ARE AVAILABLE WHERE REQUIRED.
System
Evidence
Compliance
Score
1. Are the medications stored in a clean, safe and secure environment, incorporating the manufacturer's recommendation(s)?
Systems are partially in place
There is evidence
61-80% compliance
2. Does sound inventory control practise guide the storage of medications throughout the organisation?
Systems are in place
There is evidence
61-80% compliance
3. Is the organisation defining a list and mechanism for storage of high-risk medication(s) including look-alike and sound-alike medications?
Systems are in place
There is evidence
41-60% compliance
4. Is the high-risk medication stored in areas of the organisation where it is clinically necessary?
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Systems are in place
There is evidence
61-80% compliance
5. Is the list of emergency medications defined and stored uniformly?
Systems are in place
There is evidence
61-80% compliance
6. Are emergency medications available all the time and replenished promptly when used?
Systems are in place
There is evidence
61-80% compliance
MOM.3:MEDICATIONS ARE PRESCRIBED SAFELY AND RATIONALLY.
System
Evidence
Compliance
Score
1. Is medication prescription in consonance with good practices/guidelines for the rational prescription of medications?
Systems are in place
There is evidence
41-60% compliance
2. Is the organisation adhering to the determined minimum requirements of a prescription?
Systems are in place
There is evidence
61-80% compliance
3. Are drug allergies and previous adverse drug reactions ascertained before prescribing?
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Systems are in place
Some evidence
61-80% compliance
4. Does the organisation have a mechanism to assist the clinician in prescribing appropriate medication?
Systems are in place
Some evidence
61-80% compliance
5. Does the implementation of verbal orders ensure safe medication management practices?
Systems are in place
There is evidence
61-80% compliance
6. Is the audit of medication orders/prescriptions carried out to check for safe and rational prescription of medications?
Systems are in place
There is evidence
61-80% compliance
7. Is corrective and/or preventive action(s) taken based on the audit, where appropriate?
Systems are in place
There is evidence
61-80% compliance
8. Does the reconciliation of medications occur at transition points in patient care?
Systems are in place
There is evidence
61-80% compliance
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MOM.4:MEDICATIONS ORDERS ARE WRITTEN IN A UNIFORM MANNER.
System
Evidence
Compliance
Score
1. Is the organisation ensuring that only authorised personnel write orders?
Systems are in place
There is evidence
61-80% compliance
2. Are the medication orders written in a uniform location in the medical records that also reflect the patient's name and unique identification number?
Systems are in place
There is evidence
61-80% compliance
3. Are the medication orders legible, dated, timed and signed?
Systems are in place
There is evidence
61-80% compliance
4. Is the medication order complete with the name of the medicine, route of administration, strength to be administered and frequency/time of administration?
Systems are in place
There is evidence
61-80% compliance
MOM.5:MEDICATIONS ARE PRESCRIBED SAFELY AND RATIONALLY.
System
Evidence
Compliance
Score
1. Is the dispensing of medications done safely?
Systems are in place
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There is evidence
61-80% compliance
2. Are the medication recalls handled effectively?
Systems are in place
There is evidence
61-80% compliance
3. Are near-expiry medications handled effectively?
Systems are in place
There is evidence
61-80% compliance
4. Are dispensed medications labelled?
Systems are in place
There is evidence
61-80% compliance
5. Are high-risk medication orders verified before dispensing?
Systems are in place
There is evidence
61-80% compliance
6. Is the return of medications to the pharmacy addressed?
Systems are in place
There is evidence
61-80% compliance
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MOM.6:MEDICATIONS ARE ADMINISTERED SAFELY.
System
Evidence
Compliance
Score
1. Is the administration of medication done in a safe manner?
Systems are in place
There is evidence
61-80% compliance
2. Is prepared medication labelled before preparation of a second drug?
Systems are in place
There is evidence
61-80% compliance
3. Is the patient identified before administration?
Systems are in place
There is evidence
61-80% compliance
4. Is the medication verified by the medication order and physically inspected before administration?
Systems are in place
There is evidence
61-80% compliance
5. Is strength, route and timing verified by the order before administration?
Systems are in place
There is evidence
61-80% compliance
6. Are measures to avoid catheter and tubing mis-connections during medication administration implemented?
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Systems are in place
There is evidence
61-80% compliance
7. Is medication administration documented?
Systems are in place
There is evidence
61-80% compliance
8. Are measures to govern patient's self-administration of medication simplemented?
Systems are in place
There is evidence
61-80% compliance
9. Are measures to govern patient's medications brought from outside the organisation implemented?
Systems are in place
Some evidence
61-80% compliance
MOM.7:PATIENTS ARE MONITORED AFTER MEDICATION ADMINISTRATION.
System
Evidence
Compliance
Score
1. Are patients monitored after medication administration?
Systems are in place
There is evidence
61-80% compliance
2. Are medications changed where appropriate based on the monitoring?
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Systems are in place
There is evidence
61-80% compliance
3. Does the organisation capture near-misses, medication errors, and adverse drug reactions?
Systems are in place
There is evidence
61-80% compliance
4. Are near-misses, medication errors, and adverse drug reactions reported and analysed within a specified time frame?
Systems are in place
There is evidence
61-80% compliance
5. Are corrective and/or preventive action(s) taken based on the analysis?
Systems are in place
Some evidence
41-60% compliance
MOM.8:NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES, CHEMOTHERAPEUTIC AGENTS AND RADIOACTIVE AGENTS ARE USED IN A SAFE
MANNER.
System
Evidence
Compliance
Score
1. Are narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents used safely?
Systems are in place
There is evidence
41-60% compliance
2. Are narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents prescribed by appropriate caregivers?
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Systems are in place
There is evidence
61-80% compliance
3. Are narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents drugs stored securely?
Systems are in place
There is evidence
21-40% compliance
4. Are chemotherapy and radioactive agents prepared properly and safely and administered by qualified personnel?
Systems are in place
There is evidence
61-80% compliance
5. Is a proper record kept of the usage, administration and disposal of narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents?
Systems are in place
There is evidence
61-80% compliance
MOM.9:IMPLANTABLE PROSTHESIS AND MEDICAL DEVICES ARE USED IN ACCORDANCE WITH LAID DOWN CRITERIA.
System
Evidence
Compliance
Score
1. Does the written guidance address the procurement and usage of implantable prostheses?
Systems are in place
There is evidence
41-60% compliance
2. Are the patient and his/her family counselled on the usage of the implantable prosthesis and medical devises including any precautions?
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Systems are in place
There is evidence
61-80% compliance
3. Are the batch and serial numbers of the implantable prosthesis and medical devises recorded in the patients' medical records, the master logbook and the
discharge summary?
Systems are in place
There is evidence
61-80% compliance
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