Maldives

National Medication
Practice Standard

Ministry of Health
Republic of Maldives
Contents

Stakeholder Consultation ................................................................................................................................................. 3

Working group members .................................................................................................................................................. 4

Acknowledgment ................................................................................................................................................................. 5

Abbreviations ........................................................................................................................................................................ 6

Glossary ................................................................................................................................................................................... 7

Introduction .......................................................................................................................................................................... 9

Methodology ......................................................................................................................................................................... 10

Standards ................................................................................................................................................................................ 11

Standard 1: Clinical governance and application of quality improvement systems .................................... 12

1.1 Quality improvement systems ................................................................................................................... 12

1.2 Criteria: Governing body ............................................................................................................................. 12

Standard 2: Standardised processes for prescribing, administering, and monitoring medicines.. ............ 14

2.1 Criteria: Prescribing ....................................................................................................................................... 14

List of Standard Abbreviation to be used in a prescription ................................................................................... 15

2.2 Criteria: Verbal/Telephone Orders .......................................................................................................... 15

2.3 Criteria: Administering ............................................................................................................................... 16

2.4 Criteria: Monitoring medication ............................................................................................................. 17

2.5 Criteria: Documentation ............................................................................................................................. 18

Standard coding reasons for non-administration of a dose ..................................................................................... 19

Standard 3: Safe preparation, dispensing, storing & disposal of medication. . ............................................... 21

3.1 Criteria: Preparation ..................................................................................................................................... 21

3.2 compounding .................................................................................................................................................. 22

3.3 Criteria: Dispensing ...................................................................................................................................... 22

3.4 Criteria: Storing ............................................................................................................................................ 24

3.5 Criteria: High risk medications ................................................................................................................ 25

3.6 Controlled Drugs ........................................................................................................................................... 25

3.7 Controlled Drugs ........................................................................................................................................... 26

3.8 Criteria: Disposing ........................................................................................................................................... 26

Maldives National Medication Standard Version 2, 2024 Page 1

Standard 4: Shared Decision Making & Partnering with patients. .................................................................... 28

4.1 Criteria: Shared Decision making ............................................................................................................ 28

4.2 Criteria: Partnering with patients ........................................................................................................... 28

Standard 5: Medication Reconciliation ....................................................................................................................... 30

5.1 Criteria: Medication reconciliation ......................................................................................................... 30

5.2 Criteria: Adverse drug reaction ................................................................................................................ 31

Standard 6: Professional responsibility and accountability ................................................................................. 32

6.1 Criteria: Scope of practice ............................................................................................................................. 32

6.2 Criteria: Responsibility & Accountability ........................................................................................... 32

6.3 Nurturing Trusting Patient Relationships and Ensuring Safety ......................................................... 33

Recommendations ............................................................................................................................................................... 34

References .............................................................................................................................................................................. 37

Page 2 Maldives National Medication Standard Version 2, 2024

Stakeholder Consultation

Aishath Shamila Mohamed, Deputy Director Nursing, IGMH

Aminath Waheeda, SRN, H.dh. Makunudhoo Health Center

Aminath Shiyama, Head Nurse Emergency, Treetop Hospital

Aminath Samha, Pharmacist, Chairperson, Maldives Pharmacy Professionals Alliance

Assistant Professor Asma Ibrahim Sulaiman, Dean Faculty of Health Sciences, Villa College

Dr Ali Aafee, Neuro Surgeon IGMH

Fathimath Limya, Health Quality & Safety Compliance Analyst, Quality Assurance and Regulations Division,
Ministry of Health

Gulisthan Esa, General Nurse, Quality Assurance and Regulations Division, Ministry of Health

Huzaimath Shakir, SRN, ASMH

Haleemath Athiza, SRN, Sh. Kanditheemu Health Center

Kadheeja Abdul Majeed, CN, Fuahmmulah Hospital

Mariyam Zulfa, AEH

Mariyam Shifana Hussain, RN, MNA

Mariam Gasim, CN, KRH

Mariyam Sama, RN, Society for Health Education

Nasfa Ibrahim, SRN, IGMH

Sheereena Ahmed, Nursing Director, KRH

Sheela Mufeed, SRN, Fuahmmulah Hospital

Thasleema Usman, Commissioner of Quality Assurance, Ministry of Health

Thoiba Abdul Hakeem, Head Critical care Nursing, ADK

Maldives National Medication Standard Version 2, 2024 Page 3

Working group members
Dr Fathimath Shifaza, Flinders University, South Australia, Adjunct EBPHC Maldives

Ms Aminath Zeeniya, Aasandha Company Limited

Ms Aishath Hamid, EBPHC Maldives.

DOCUMENT RECORD

Version No Version Date Description of change

1 19th May 2009 Initial release
2 9th May 2024 Second release

DOCUMENT NUMBER: MOH-QA/S/24/167-0

AUTHOR EBPHC Maldives

ENDORSED BY: Uza. Thasleema Usman

Commissioner of Quality Assurance

PUBLISHED BY: Ministry of Health in collaboration with WHO Maldives

Page 4 Maldives National Medication Standard Version 2, 2024

Acknowledgement

Medication practice standards are crucial guidelines that ensure safe, effective, and responsible use of medications
in healthcare settings. It also outlines accountabilities and responsibilities when performing all activities like, but
not limited to storage, administration, dispensing, inventory management and safe disposal. These standards help
reduce medication errors, adverse drug reactions, and other safety risks, ultimately safeguarding patient well-
being and ensuring staff safety. Standardized medication practices facilitate communication and collaboration
among healthcare team members, including physicians, nurses, pharmacists, and other allied health professionals.
Consistent practices will ensure that everyone involved in patient care understands their roles and responsibilities
regarding medication management. Additionally, having a consistent reporting system and providing care based
on guidelines can help prevent 75% of occurrence of harm in to hospitalized patients (Mohammed et al., 2022)

Compliance with medication practice standards demonstrates commitment to patient safety and quality of care,
fostering trust and confidence among patients, their families, and the broader community. Patients are more likely
to trust healthcare providers and institutions that adhere to recognized standards of practice. Updating and
publishing these standards also bring about accountability of Ministry of Health to orient staff on these standards
and conduct audits to ensure compliance.

I sincerely appreciate the ongoing support provided by the World health organization, throughout the
development of this standard, I would like to acknowledge EBPHC Maldives For the scoping review and
development of the current guideline. I also extend my gratitude to all stakeholders, individuals and my team at
Quality Assurance and Regulatory Division of Ministry of Health who have contributed to the development of
this standard.

The effectiveness of this standard hinges upon its adoption by healthcare professionals and stakeholders across
both government and the public sector. I urge all health care professionals to use the standards for safety and
quality of patient care.

Thasleema Usman

Commissioner of Quality Assurance

Maldives National Medication Standard Version 2, 2024 Page 5

Abbreviations

ADR- Adverse Drug Reaction

AEH: Addu Equatorial Hospital

ASMH: Abdul Samadh Memorial Hospital

CN: Clinical Nurse

CPD: Continuing Professional Development

IGMH: Indira Ghandi Memorial Hospital

IMAC-Interim Medication Administration Chart

KRH: Kulhudhufushi Regional Hospital

LASA: Look-alike, sound-alike

MNA: Maldivian Nursing Association

MR- Medicine Reconciliation

MFDA: Maldives Food and Drug Authority

OPD: Outpatient Department

PFML-Patient Friendly Medication List

POM: Prescription Only Medicines

QI: Quality Improvement

SRN: Senior Registered Nurse

SA: Self- administration

SOP: Standard of Practice

WHO: World Health Organization

Page 6 Maldives National Medication Standard Version 2, 2024

Glossary

For the purpose of this standard, the following terms are defined as stated below.

Adverse drug reaction (ADR) is defined as a noxious or unintended reaction to drug or agent which occurs at
doses used in humans for prophylaxis, diagnosis, therapy or for the modification of physiological function. This
excludes accidental/unintentional overdose (Coleman & Pontefract, 2016).

Patients: The people, patients or residents who benefit from registered nursing care. A patient may be an
individual, a family, group, community, or population.

Controlled Drugs: medicines that can only be supplied by a pharmacist on prescription and are subject to tight
restrictions because of their potential to produce addiction. These includes Buprenorphine, fentanyl,
hydromorphone, methadone, morphine, oxycodone, talpentadol and pethidine (Yun et al., 2015).

Compound: means for the purpose of these guidelines, the extemporaneous preparation and supply of a single
‘unit of issue’ of a therapeutic product intended for supply for a specific patient in response to an identified need.
The practice of compounding is classified in these guidelines as either simple or complex compounding. Unless
otherwise stated, the guidance provided in these guidelines applies to both simple and complex compounding
(Australian Commition on Safety and Quality in Healthcare, 2022; Pharmacy Board of Australia, 2017).

Simple compounding means the preparation and supply of a single ‘unit of issue’ of a therapeutic product intended
for supply for a specific patient in response to an identified need. It routinely involves the compounding of
products from formulations published in reputable reference (Australian Commition on Safety and Quality in
Healthcare, 2022; Pharmacy Board of Australia, 2017).

Complex compounding means the preparation and supply of a single ‘unit of issue’ of a therapeutic product that
is intended for supply for a specific patient and that requires or involves special competencies, equipment,
processes or facilities. Examples are sterile preparations and preparations containing ingredients that pose an
occupational health and safety hazard (such as cytotoxins or hormones), micro-dose single unit dosage forms
containing less than 25mg (or up to 25 per cent by weight or volume) of active ingredient and sustained-release or
other modified-release preparations (Pharmacy Board of Australia, 2017).

Cold chain management: the system of transporting and storing temperature-sensitive medicines and vaccines,
within their defined temperature range at all times, from point of origin (manufacture) to point of administration,
to ensure that the integrity of the product is maintained (Gogou et al., 2015).

Distribution: systematic and reliable delivery of medicines to all health care facilities (Pharmacy Board of
Australia, 2017).

Guideline: a principle or criterion that guides or directs action. Guideline development emphasises using clear
evidence from the existing literature, rather than expert opinion alone, as the basis for advisor materials (Nursing
and Midwifery Board Ireland, 2020)

Healthcare Professional: professionals who are qualified by education and/or experience to provide health care
and are practicing medical practitioners, dental practitioners, nurses, midwives, allied health professionals
(Healthcare Professional Act, 2015).

Maldives National Medication Standard Version 2, 2024 Page 7

High-risk medicines: Are those medicines that have a high risk of causing significant patient harm or death when
used in error. Although errors may or may not be more common than with other medicines, the consequences of
errors with these medicines can be more devastating (Pharmacy Board of Australia, 2017).

Interval frequencies: are hourly frequencies such as 4 hourly, 6 hourly, 8 hourly.

Medication: In this document, medication refers to all scheduled drugs, over the counter medication, blood and
blood products, biologics, vaccines, and natural health products (Department of Health, 2020) .

Medicines Management: Medicines management covers a number of tasks including prescribing, ordering,
dispensing, receiving/transporting, storing, assessing, preparing, assisting, administering, disposing and reviewing
individuals with their medicines (Nursing and Midwifery Board Ireland, 2020; Pharmacy Board of Australia, 2017).

Medication Reconciliation: A process for obtaining and documenting a complete and accurate list of a patient’s
current medicines upon admission and comparing this list to the prescriber’s admission, transfer and/or discharge
orders to identify and resolve discrepancies(Stark et al., 2020).

Near Miss: An event, situation, or error that took place but was captured before reaching the patient (Institute for
Safe Medication Practices, 2009).

Over the counter medications: Medications that can be sold without prescription (Department of Health, 2020).

Omission: failure to do something, especially something that a person has a moral or legal obligation to do.

Procurement: purchasing medicines of reliable quality at economical prices (Stevenson, 2010).

Protocol: an established set of rules used to complete tasks or a set of tasks (Stevenson, 2010).

Scheduled frequencies are frequencies such as TWICE a day, THREE times a day.

Storage: the site/place and conditions under which medicines are kept until dispensing or administration
(Pharmacy Board of Australia, 2017).

Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of
frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) (Australian Commition on Safety and
Quality in Healthcare, 2022; Stark et al., 2020).

Self-administration: the independent use of a medication by a patient in a manner that supports the management
and administration of their medications.

Time critical medicines are defined as medicines were early or delayed administration by more than 30 minutes
from the prescribed time for administration may cause harm to the patient or compromise the therapeutic effect
resulting in suboptimal therapy (Pharmacy Board of Australia, 2017).

Page 8 Maldives National Medication Standard Version 2, 2024

Introduction
Within the framework of healthcare, medications stand as an integral component, playing a vital role in the
prevention and treatment of illnesses, enhancement of life quality, and overall extension of life expectancy (World
Health Organization, 2017). The responsibility for ensuring the judicious use of medicine rests on healthcare
professionals, who actively influence treatment decisions, communicate effectively with patients, and collaborate
with fellow healthcare practitioners. Despite the significant benefits of medications, challenges arise at various
stages, from prescription to dispensing and administration, introducing potential risks to individuals (Wood,
2020). The consequences of unsafe medication management extend to both patient and healthcare system levels,
manifesting in injuries, therapy failure, exacerbated illnesses, increased healthcare service utilization, and
substantial financial burdens (Ahern et al., 2014; Hwabejire et al., 2013; Panagioti et al., 2019). Hence to mitigate
this increased patient safety risk, healthcare experts recommend the use of medication standards to ensure that
clinicians safely prescribe, dispense, and administer appropriate medications and monitor their use of them. It is
also intended to ensure that patients are informed about medicines and empowered to achieve the best practices
in medication management through the implementation of proven and sustainable strategies integrated across all
health settings. Since 2017, medication safety in transitions of patient care has become a key priority area for the
third WHO’s Global Patient Safety Challenge ‘medication without harm’(Olsen & Sletvold, 2022). Moreover,
medication safety is central to the WHOs Global Patient Safety Action Plan 2021–2030, where the goal is to
achieve the maximum possible reduction in avoidable harm due to unsafe healthcare(World Health Organization,
2020).

This document serves as a comprehensive guide, addressing a wide spectrum of aspects related to medications,
from their development and manufacturing to distribution, prescription, and administration. By outlining
standardized protocols and criteria, the National Medication Standard Document aims to harmonize practices
across the healthcare system, fostering consistency and accountability.

Key features of the National Medication Standard Document include:

Quality Assurance: Establishing benchmarks for the quality of pharmaceutical ingredients,

manufacturing processes, and finished products to guarantee the safety and efficacy of medications.

Regulatory Compliance: Providing a framework for compliance with national regulations, ensuring that
all stakeholders in the medication supply chain adhere to legal requirements and industry best practices.

Safety Protocols: Outlining safety standards and protocols for the prescription, dispensing, and
administration of medications to minimize adverse events and enhance patient safety.

Interoperability: Promoting compatibility and interoperability between different healthcare systems,

allowing for seamless information exchange and coordination in medication management.

Innovation and Research: Encouraging advancements in medication development by incorporating

provisions for research, development, and the introduction of novel therapies while maintaining a robust
regulatory oversight.

Education and Training: Facilitating the continuous education and training of healthcare professionals
to ensure a knowledgeable workforce capable of implementing and adhering to the established
standards.

These standards always apply to all regulated members regardless of role or practice setting and are
specific to medication management. The standards are grounded to code of ethics in Health
Professionals Act HPA.

Maldives National Medication Standard Version 2, 2024 Page 9

Methodology
A scoping review was conducted in accordance with the JBI methodology (Peters et al., 2017) for scoping reviews
to assess the national standards worldwide. An initial draft of the Maldives national medication standard was
developed and an online and face-to-face Delphi study was used to reach consensus between a panel of
stakeholders. The Delphi technique involves an iterative process in which respondents anonymously respond to
questions or items in an attempt to reach a group consensus (Barrett & Heale, 2020).

Standards
These standards identify the expectations for regulated members for medication management. The criteria in the
following standards illustrate how the regulated member must meet the standard, and all criteria must be met to
achieve the standard. It is e criteria are not written in order of importance.

Page 10 Maldives National Medication Standard Version 2, 2024

 Maldives National Medication Practice Standard

Clinical governance and application of

quality improvement systems
01 Governing body
Quality improvement systems

Standardised processes for prescribing,

admisnistering and monotoring medicines
Prescribing
Verbal/Telephone Orders
Administering
Monitoring medication
02
Documentation

Safe preparation, dispersing, storing &

disposal of medication

03 Preparation/compounding
Dispensing
Storing
High risk medication
Disposing

Shared Decicion making & partnering with

consumers
Shared Decision making
Partnering with consumers
04
Medication Reconciliation

05 Medication reconciliation
Adverse drug reaction

Professional responsibility and

accountability
Scope of practice
Responsibility
Accountability
06
Standard 1 : Clinical governance and application of quality
improvement systems
1.1 Criteria: Quality improvement systems
1.2 Criteria: Governing body

Clinical governance is an integrated set of leadership behaviours, policies, procedures, responsibilities,

relationships, planning, monitoring and improvement mechanisms that are implemented to support safe, quality
clinical care and good clinical outcomes for each patient.

1.1 Criteria: Quality improvement systems

1.1.1 Use of shelf reminders, checklists, and alerts. These should be built into information technology
systems where possible in all the healthcare services.

1.1.2 Low-level risk-reduction strategies (i.e. staff education and information) should be used
together with high-leverage risk-reduction strategies, such as forcing functions and fail safes
(such as limiting access or use, constraints, barriers or standardisation.

1.1.3 A regular review of incidents and near-misses and the use of prospective analysis and re-design
of systems to prevent recurrence of the same errors.

1.1.4 Pharmacists who compound products must have appropriate risk management processes in
place to manage risks associated with the compounded product and the workplace (for
maintenance of facilities, quality assurance of products including microbial testing,
occupational health and safety adherence, professional indemnity insurance arrangements, etc.).

1 . 1 .5 Conduct routine audits of medication management practices to ensure safe and effective care
for patients.

1.1.6 The healthcare service to develop an information system to collect and review data related to
medication practices for improvement.

1.2 Criteria: Governing body

1.2.1 The healthcare service sets up and uses clinical governance systems to improve the safety and
quality of healthcare for patients and uses its systems to support the workforce to address and
mitigate clinical safety risks.

1.2.2 The healthcare service has processes to support its workforce to understand and fulfill their
assigned safety and quality roles and responsibilities.

1.2.3 Develop clear roles and responsibilities for clinical governance within the health care service.
Number of people who fill these roles depends on the size of the service. (In a health center or
small clinic- One person can fulfill all of these roles, while atoll hospital few people can fill all
of these roles).

Page 12 Maldives National Medication Standard Version 2, 2024

 Patients - participate as partners to the extent that they choose. This can be about their
health care, and in service design and governance.

Healthcare professionals: Work within, and are supported by, well designed clinical
systems to deliver safe, high-quality clinical care. Healthcare providers are responsible for
the safety and quality of their own professional practice and codes of conduct.

Managers: Are primarily responsible for ensuring that the systems that support the
delivery of health care are well-designed and perform effectively. Where managers are not
owners, they advise and inform the owners/ governing body, and operate the service within
the agreed strategic and policy parameters.

Governing body: Are ultimately responsible for ensuring the service is well run and
delivers safe, high-quality health care. They do this by establishing a strong safety culture
through an effective clinical governance system, satisfying themselves that this system
operates effectively, and ensuring there is an ongoing focus on quality improvement.

1.2.4 The healthcare service provides its workforce with orientation and training for their safety and
quality roles on commencement with the service when safety and quality responsibilities
change and when new healthcare services are introduced.

Maldives National Medication Standard Version 2, 2024 Page 13

Standard 2 : Standardised processes for prescribing, administering, and
monitoring medicines.

2.1 Criteria: Prescribing

2.2 Criteria: Verbal/Telephone Orders
2.3 Criteria: Administering

2.1 Criteria: Prescribing

2.1.1 Accurate patient weight should be documented on the medication chart for all patients.

2.1.2 The route of administration for the medicine must be clearly identified. The use of multiple
routes of administration in one prescription should be avoided for the same medicine (for
example, intravenous paracetamol / oral paracetamol)

2.1.3 Where required, the strengths of medicines must be clearly visible in terms of the dosage unit or
dose per volume of liquid, for example, mg per ml.

2.1.4 Dose adjustments must be considered when prescribing a high-risk medicine for patient groups
such as overweight or underweight patients, and patients with existing clinical conditions (such
as renal or hepatic impairment) that may affect drug metabolism and excretion.

2.1.5 Therapeutic guidelines should be followed for medicines where dosing is complex and the
duration of therapy substantially increases the risk of toxicity, for example, aminoglycosides.

2.1.6 When prescribing IV antibiotics, use hourly (known as interval) frequencies (e.g., 6 hourly),
rather than scheduled frequencies (e.g. FOUR times a day). This will reduce the risk of
additional, unintended doses being scheduled and the nurses having to do extensive
rescheduling.

2.1.7 Local health service policy/ guidelines will outline when nurses can initiate medicines and will
specify a limitation on nurse-initiated medicines such as “for one dose only” or “for a maximum
of 24 hours only”. Generally, the capacity applies to a limited list of medicines only. Typically,
this includes simple analgesics, aperients, antacids, cough suppressants, sublingual nitrates,
inhaled bronchodilators, artificial tears, sodium chloride 0.9% flush, or IV infusion to keep IV-
line(s) patent as per local policy.

Page 14 Maldives National Medication Standard Version 2, 2024

List of Standard Abbreviation to be used in a prescription
Once Daily OD
Night HS
Twice a day BD
Three times a day TDS
8hrly
Four times a day QID
6hrly
Every hourly QH
Every two hourly Q2H
Every two hourly Q3H
As needed SOS
Immediate STAT

2.2 Criteria: Verbal/Telephone Orders

2.2.1 Only an authorized health care professionals (i.e., doctor, registered nurse, CHW) can take
telephone orders.

2.2.2 Local Health service policy/guidelines will outline whether telephone orders are allowed and
under what circumstances they are to be used.

2.2.3 Verbal orders should not be given to administer an unprescribed medicine, except in an
emergency.

2.2.4 When recording a verbal/telephone order, the following must be documented:

2.2.4.1 date and time prescribed

2.2.4.2 generic name of medicine
2.2.4.3 route of administration
2.2.4.4 dose to be administered.
2.2.4.5 frequency medicine is to be administered.
2.2.4.6 initials of two healthcare practitioners to confirm the verbal order heard and double-
checked.
2.2.4.7 - name of the doctor giving verbal order
2.2.4.8 - time of administration
2.2.4.9 - initials of person who administers the medicine

2.2.5 Authentic electronic mail orders and orders given through telemedicine can be accepted (text
messages from prescriber’s mobile phone should not be accepted). However, verification must
be made whenever necessary.

2.2.6 Faxed and printed email orders should be filed in patient’s charts.

2.2.7 The prescriber should confirm the order by signing in the patient’s chart as soon as possible and
not later than 6 hours.
Maldives National Medication Standard Version 2, 2024 Page 15
2.3 Criteria: Administering

2.3.1 The healthcare practitioner administering the medication should review the patient’s
medication chart before administering the medication to the patient.

2.3.2 Healthcare professionals administering any medicine should have current knowledge of
indication, mechanism of action, dosage, precautions, contraindications, interactions with food
or other medicines, and side effects of the medication.

2.3.3 All healthcare professionals administering medicines should have knowledge of and skills if
using any equipment for administering medicine (eg. nebulisers, infusion pumps etc).

2.3.4 Medicines should be scheduled so that medicine is administered on the same times each day
and doses are spaced appropriately so that medicine levels are stable. When a new medicine is
started outside the regime, then a stat dose can be given.

2.3.5 All healthcare services ensure policies should outline standardized medication administration
times to accommodate the timing of meals, minimize disturbances to night sleep of the patient
(last dose any scheduled medications should not be later than 10 pm) and to eliminate the need
for individual interpretation of when the medications should be given.

2.3.6 Exceptions to standard drug administration times may be appropriate for patients who self-
administer chronic medications, stagger numerous piggyback IV medications, or keep a time-
critical chronic medication on the same schedule used before admission. (While it may seem
best to try to keep patients who take any type of chronic medication on the same
administration schedule they were using at home, medication administration throughout the
day during nonstandard times is prone to omissions; thus, administration during standard
times is recommended. QID medicines should be given at 6 am, 12 pm, 6 pm, and 10 pm. TID
medicines should be given at 6 am, 2 pm and 10 pm. BID medicines should be given at 6 am and
6 pm or 8 am and 8 pm. These times should also be used in transcribing.

2.3.7 The healthcare practitioner writing the order must enter the frequency and administration
time(s) when writing the medication order. Time should be entered using the 24-clock (this
nomenclature is the global standard).

2.3.8 Disposable syringes must not be reused, single-dose vials should not be used for multiple
dosages, and a new syringe must be used each time to draw medication from a multi-dose vial
(Limya, 2020).

Page 16 Maldives National Medication Standard Version 2, 2024

 Morning OD 0800
Night HS 1800 or 2000
Twice a day bd 0800 2000
Three times a day tds 0800 1400 2000
*Antibiotics 6 hourly 6hrly 0600 1200 1800 2400
Antibiotics 8 hourly 8hrly 0800 1400 2200
Four times a day qid 0600 1200 1800 2200
Adapted from Australian Commission on Safety and Quality in Health Care(Australian Commision on Safety and Quality in Healthcare, 2019)

Recommendation is that all medication needs to be administrated by 2200hrs

2.3.9 Health services should also define targeted timeframes for administering first doses and loading
doses of key medications, such as IV anti-infective agents, IV anticoagulants, and IV
antiepileptic medications, where timeliness is critical (e.g., an emergency department patient
with suspected sepsis should not wait several hours for the administration of a prescribed anti-
infective). The targeted timeframes for first or loading doses of medications should be
accompanied by procedures that facilitate achievement of the administration time goals.

2.3.10 Health services establish procedures for healthcare practitioners to follow if the administration
of a time-critical scheduled medication will be or has been delayed or administered early
beyond allowable expectations.

This procedure should include:

prescriber notification when an adverse outcome is anticipated or has occurred

documentation in the patient’s chart regarding the reason administration of the dose
was early or delayed, and
evaluation of the need to change the timing of future doses.

2.4 Criteria: Monitoring medication

An essential component of the medication process related to the administration of medications is monitoring and
assessing the patient by healthcare practitioners.

2.4.1 Patient should be monitored after medicine administration in accordance with local protocols
and guidelines.

2.4.2 Health care Practitioners should be alerted in clinical handover to the use of any high-risk
medicines.

2.4.3 The health service practice should develop processes for managing high-risk, high-alert
medications and Look-alike, sound-alike (LASA) medications.

2.4.4 In case of an adverse drug reaction, emergency medicines and equipment should be easily
available.

Maldives National Medication Standard Version 2, 2024 Page 17

2.5 Criteria: Documentation
2.5.1 In the event of non-administration of a medicine, standard abbreviations must be used
consistently and circled to avoid confusion between the code and practitioner’s initial (See
Figure 1). A blank record provides no information about the reason for non-administration but
may also indicate that the medicine was given but not signed. It is recommended that the
reason for non-administration is documented and communicated in the notes.

A Absent

F Fasting

NA Not Available

Standard coding
reasons for
R Refused

non-administration
of a dose SA Self-administered

V Vomited

W Withheld

L On Leave

Page 18 Maldives National Medication Standard Version 2, 2024

Standard coding reasons for non-administration of a dose
Code Explanation Action
The patient is temporarily away Administer delayed dose if possible; record the time. Verify
from the ward due to reasons such next scheduled medication time and administer it before the
as undergoing diagnostic tests, patient leaves for scheduled procedures, tests, or treatments,
A
Absent
procedures, or treatments, or in
cases where the patient is
including dialysis. Inform patients of their regular medication
times and encourage presence in the ward during these periods.
unaccounted for or has left the
ward.

Prescriber guidance (e.g., from an anaesthetist/ treating

doctor) is essential to determine medicines for fasting, fasting
duration, and therapy resumption.
An anesthetist team may create a local guidance document for
fasting patients.
The patient is fasting for a Document and communicate directions.
procedure or surgery.
F This is not a preventable omission unless the dose was intended
to be given even during fasting.
Fasting *Fasting should not be confused with or considered the same as
“nil by mouth.” Use "Withheld (W)" coding when “nil by
mouth” applies briefly; otherwise, relevant oral prescriptions
should be canceled by, or at the direction of, the prescriber.

Pharmacy: Maintain stock and supply of approved medicines.

For out-of-stock items, make alternative arrangements,
the required medication is
communicate with prescribers and wards about the situation.
NA inaccessible for administration or
use.
Nurse: obtain ward supply if possible. Contact the prescriber if
necessary. Document and communicate actions in the notes.
Not Available
Commence appropriate therapy once the stock is obtained.

Document the patient's refusal to take their regular medication

in the medical records, including the reason provided by the

R
Patient refusing to take a regular patient if applicable. Notify the attending healthcare provider
medication and discuss alternative options with the patient, such as
Refused further education on the importance of the medication,
potential side effects, or alternative treatment options.

SA
Self-administered
This code is utilized to signify
when a patient has independently
During the hospitalization, it is crucial to highlight that
nursing/midwifery staff must observe and approve all
taken a medication. medication administrations.

V
Vomiting code is used to indicate Apply the vomiting code to indicate medication dosing
both before (unable to take) and omission, capturing instances both before (due to inability to
Vomited after (dose not absorbed) take) and after (due to non-absorption) administration.
medication dosing omission. Top of Form

W
Withheld
Used when there is a clinical reason withholding the dose should be documented and
to withhold a dose communicated to the prescriber as soon as practicable.

L when the patient has approved

leave from hospital for a day
Assign an 'L' code when a patient has approved leave from the
hospital for a day or a week, as medication administration is
On Leave not observed during this period.

Maldives National Medication Standard Version 2, 2024 Page 19

 Hospitals should provide clear guidelines about the
appropriate actions to be taken when a medicine is
not administered within the accepted period of
tolerance.

2.5.2 Health Service should provide clear guidelines about the appropriate actions to be taken
when a medicine is not administered within the accepted period of tolerance.

2.5.3 If there is any change in the patient treatment plan, the reason for this change and the
person(s) notified should be documented.

2.5.4 All aspects of controlled drug administration should be recorded properly in the patient
chart and then countersigned.

2.5.5 Documentation should be stored in a safe, systematic and secure manner that allows timely
and accurate retrieval, while reducing the risk of unauthorised access and failure of
confidentiality. All documents must be securely stored in accordance with professional
standards and relevant legislation.

Page 20 Maldives National Medication Standard Version 2, 2024

Standard 3 : Safe preparation, dispensing, storing & disposal of
medication.

3.1 Criteria: Preparation

3.2 Compounding
3.3 Criteria: Dispensing
3.4 Criteria: Storing
3.5 Criteria: High risk medications
3.6 Controlled Drugs
3.7 Criteria: Disposing

Selection, procurement and distribution of medicines should be done based on the most current or updated
National Medicine Policy to ensure safe, effective, affordable and good quality medicines are readily available for
dispensing and administration.

3.1 Criteria: Preparation

3.1.1 Healthcare practitioners needs to be vigilant when preparing medications (avoid distractions
and interruptions).

3.1.2 Healthcare practitioners needs to be diligent in all medication calculations.

Maldives National Medication Standard Version 2, 2024 Page 21

3.2 compounding

3.2.1 In preparing a compounded medicine, a corresponding formulation in a reputable reference

should be used by the pharmacist when available (refer to Reference texts and other sources
of information relevant to compounding in these guidelines for examples of reputable
references).
3.2.2

3.2.2.1 A compounded medicine should be prepared only in circumstances where:

3.2.2.2 an appropriate commercial product is unavailable.

a commercial product is unsuitable (e.g., if a patient experienced an allergy to an

3.2.2.3 excipient in the commercial product), or

when undertaking research sanctioned by a recognised National Health Research

3.2.2.4 Council.

Pharmacists entering the profession are expected to have had the appropriate
education and training to compound medicines and are deemed competent to
undertake ‘simple compounding’. Simple compounding may routinely involve
compounding products using other formulations for which information confirming
3.2.2.5 quality, stability, safety, efficacy and rationality is available.

When pharmacists extend their scope of practice to include complex compounding,

they must be able to demonstrate that they have met the requirements of the
Continuing Professional Development (CPD) registration standard by maintaining
evidence of the CPD activities they have done to achieve competence to undertake
complex compounding.

3.3 Criteria: Dispensing

3.3.1 Medicines should be dispensed only by a qualified and authorized pharmacist at the proper
time.

3.3.2 The dispensers should have the knowledge, skill and judgment to dispense the medicine
safely, effectively and ethically.

3.3.3 All orders must be reviewed for appropriateness before a medicine is dispensed. Medicine
order evaluation includes interactions, allergies, and contraindications.

3.3.4 If any problem is identified with the medicine order, it should be communicated with the
prescriber and resolved before the medicine is dispensed.

3.3.5 Dispensing for inpatients, discharges and outpatients complies with all legislative,
professional and best practice requirements for dispensing.

Page 22 Maldives National Medication Standard Version 2, 2024

 3.3.6 Dispensing should be involve.

Receiving and reading the prescription

Selecting the drug to dispense

Checking expiry date

Label the product clearly and appropriately with name, proper route, dosage, for how long
to take, and also the expiry date.

Completing a final check for accuracy

3.3.7 Such requirements include:

Identification of patient using approved identifiers (3 points of identification required)

Labeling and relevant cautionary advisory label requirements (for discharge and outpatients)
to optimise the correct medication storage, handling and administration.

Maintenance of patient privacy/confidentiality.

Barcode scanning of dispensing label and original pack to ensure the correct selection of
medication, strength, brand, and dose form as per each label. This safety check is carried out
for all inpatient, outpatient and discharge medications, where possible.

Barcode scanning does not identify all errors, so a manual check must also occur.

In the absence of barcode scanning capability, a manual verification process is required.

An independent accuracy check of prescriptions dispensed by a pharmacist.

Provision of medication information at an appropriate level of patients’ and/or staff’s

knowledge.

Provision of a patient friendly medication list and other administration charts, e.g., complex
dosing chart, interim medication administration chart, where appropriate.

Maldives National Medication Standard Version 2, 2024 Page 23

3.4 Criteria: Storing

3.4.1 All essential medicines should be routinely stocked and stored in their original packaging to
render protection to the medicine and to retain information regarding batch numbers and
expiry dates.

3.4.2 Guidelines for proper and safe storage of medicines should be available in all places, such as
healthcare facilities and pharmacies.

3.4.3 All conditions necessary to maintain the stability of medicines should be followed when
storing medicines. These conditions include appropriate temperature, and humidity and
prevent exposure to harmful light. Pharmacists’ advice should be sought in identifying these
conditions.

3.4.4 The cold chain should be maintained during all aspects of vaccine storage. Vaccines should not
be stored in the door, in the bottom drawers, or adjacent to the freezer plate of refrigerators

3.4.5 Healthcare service ensure that refrigerators (or cool rooms) of adequate size are available for
the exclusive storage of vaccines or medicines that require storage between 2 °C and 8 °C.

3.4.6 Medicine stock should be replenished so as not to hinder availability for dispensing or
administration of medicine.

3.4.7 To minimize medication errors, look-alike and sound alike medicines should be stored
separately.

3.4.8 Perform a risk assessment of the processes in place for the handling, storage and distribution of
medicines using validated or locally endorsed audit and risk tools.

3.4.9 Once a medication is prepared for administration but not administered, it should be
considered as a stored medicine until administration.

3.4.10 Medicines stored in the wards, especially medicines in the emergency trolley, should be in the
readiest to- administer form.

3.4.11 Health care facility’s/pharmacy’s policies should be followed in storing controlled drugs.

Page 24 Maldives National Medication Standard Version 2, 2024

3.5 Criteria: High risk medications

3.5.1 A healthcare service that prescribes, stores, supplies and/or administers medicines has processes
to:

Identify high-risk medicines within the service (see table 1)

Any alterations or additions to the High-Risk Medicine Register require endorsement from
the Ministry of Health.

Safely store, prescribe, supply, administer and dispose of high-risk medicines.

High-Risk Medicine Groups

A Anti-infectives
P Potassium and other electrolytes
I Insulin
N Narcotics and other sedatives
C Chemotherapeutic agents
H Heparin and anticoagulants
other High-risk medicines identified at a unit level which do not fit the above categories

3.5.2 Each high-risk medicine included on the High-Risk Medicine Register along with its
associated individual standard will be assigned a maximum 2-year review date.

3.6 Criteria: Medication Safety Committee & High-Risk Medicines Register

3.6.1 The Medication Safety Committee in the healthcare service will be responsible for maintaining
the High-Risk Medicine Register and ensuring risk reduction strategies are effective.

3.6.2 The High-Risk Medicines Register and individual high-risk medicine standards will be made
easily accessible to all staff involved in the management of medicines via the Policy and
Guidance Documents Register on the intranet.

3.6.3 Each medicine on the high-risk medicines register will be subjected to a comprehensive risk
assessment to reduce the risk of errors that can occur across all phases of the medicine.

Maldives National Medication Standard Version 2, 2024 Page 25

3.7 Controlled Drugs

3.7.1 All controlled drugs are exclusively imported through STO. The Ministry of Health
collaborates with STO and the Narcotic Control Board to formulate the annual national
demands for controlled substances, which are then submitted to NCB (Narcotics Control
Board). NCB notifies the Ministry of Health based on these requirements, and subsequent
authorization for the importation of controlled substances is granted to STO.

3.7.2 Every establishment handling controlled drugs must adhere to storage guidelines outlined by
the MFDA. This ensures that the stocked drugs are securely maintained on the premises,
minimizing accessibility to individuals likely to misappropriate them. The security measures
implemented should meet the MFDA standards to protect both the controlled substances and
the personnel working within the establishment(Ministry of Health).

3.7.3 Maintain accurate records of controlled drugs as per MFDA guidelines, regularly cross-check
stock records, retain blue prescriptions quarterly, and keep all related records for at least two
years.

3.7.4 The handling of controlled drugs must adhere to the guidelines provided by MDFA.

3.8 Criteria: Disposing

3.8.1 All healthcare services implement policies, procedures, and guidelines for the disposal of
unused, unwanted, or expired medicines.

38.2 Controlled drugs are legislated to be destroyed by an authorized health practitioner and
witnessed by a second authorized healthcare practitioner in accordance with MFDA (Ministry
of Health).

3.8.3 Controlled drug waste waiting to be destroyed must be kept secure in a safe, separated from
other medicines in the safe, clearly marked for destruction, and may only be removed
immediately before destruction or being transferred for destruction.

3.8.4 Every healthcare facility should have designated personnel responsible for notifying the
Ministry of Health if controlled drugs expire or are withheld from use for any reason.

3.8.5 Upon closure or cessation of operations, the pharmacy must dispose of or transfer all records,
files, and drug stock in compliance with the directives provided by the Ministry of Health.

3.8.6 Pharmacies and healthcare facilities across the islands should forward lists of expired controlled
drugs to the nearby regional hospital or health center.|
3.8.7 Healthcare facilities handling cytotoxic drugs must:

3.8.7.1 Establish and label specific color-coded bins or use recognizable symbols (e.g.,
purple) for disposing of cytotoxic drugs, ensuring clear identification in areas where
these drugs are handled.

Page 26 Maldives National Medication Standard Version 2, 2024

 3.8.7.2 Ensure easy accessibility and strategic placement of these designated bins or
symbols in preparation, administration, and waste generation areas, complying with
safety standards.

3.8.7.3 Provide training to staff for proper identification and exclusive use of these bins or
symbols for cytotoxic drug waste, along with regular awareness programs.

3.8.7.4 Conduct routine inspections and audits to monitor compliance, promptly

rectifying any deviations from standard procedures.

Uphold this standard to guarantee safe disposal practices and review it periodically
3.8.7.5
to align with evolving regulatory requirements.

Maldives National Medication Standard Version 2, 2024 Page 27

Standard 4 : Shared Decision Making & Partnering with patients.

4.1 Criteria: Shared Decision making

4.2 Criteria: Partnering with patients

Clinical outcomes and patient satisfaction are likely to be better when decisions about medicines are made
jointly between the person taking the medicine and the prescriber (shared decision making)(Montori et al.,
2017; Stiggelbout et al., 2012).

4.1 Criteria: Shared Decision making

4.1.1 All service providers (such as hospitals, clinics, and pharmacies) ensure that people are
allowed to be involved in making decisions about their medicines in partnership with
professionals who prescribe medicines.

4.1.2 Healthcare professionals (such as prescribers, and pharmacists) ensure that people are allowed
to be involved in making decisions about their medicines. For example, healthcare
professionals can use patient decision aids to support shared decision-making and they should
ensure that people who take medicines have information about the potential benefits and
harms.

4.1.3 Healthcare professionals should take account of a person's values and preferences by discussing
what is important to them about treating or managing their condition(s) and their medicines.

4.1.4 Address concerns of problematic polypharmacy with the client, the inter-professional team,
and the authorized prescriber or most responsible healthcare practitioner.

Page 28 Maldives National Medication Standard Version 2, 2024

4.2 Criteria: Partnering with patients

4.2.1 Ministry of Health provides guidance and resources to health services to support them to
become more person-centered in the context of National Quality and Safety Standards.

4.2.2 The healthcare service has processes for healthcare providers to partner with patients and/or
their substitute decision-maker to plan, communicate, set, and review goals, make decisions,
and document their preferences about their current and future healthcare.

4.2.3 Healthcare service fosters partnerships with patients, carers, and families, promoting active
patient involvement, while professionals communicate tailored information addressing patient
needs, preferences, and ongoing healthcare requirements.

4.2.4 The healthcare service collaborates with patients, carers, and families to incorporate their views
and experiences into service planning, design, monitoring, and evaluation while providing
information on services, hours, costs, feedback mechanisms, and contact details for healthcare
complaints.

4.2.5 If a patient questions or expresses concern regarding a medication, stop and explore the
patient’s concerns, review the doctor’s order, and, if necessary, notify the practitioner in charge.
If the issue is not resolved, the patient could notify MFDA.

Maldives National Medication Standard Version 2, 2024 Page 29

Standard 5 : Medication Reconciliation

5.1 Criteria: Medication reconciliation

5.2 Criteria: Adverse drug reaction

Medication reconciliation means that the medicines the patient should be prescribed match those that are
prescribed. Transition points of care are particularly prone to unintended changes in medication regimes and
other medication errors.

5.1 Criteria: Medication reconciliation

5.1.1 All registered healthcare practitioners involved in Medicine Reconciliation (MR) are
responsible and accountable for the accuracy and quality of information provided to support
the medicine reconciliation process at a given point in time.

5.1.2 Each organisation ensures that each healthcare practitioner involved with medicine
reconciliation meets minimum education and training requirements every year. Learnings from
the measures are incorporated into ongoing implementation and education and training
requirements.

5.1.3 An all-encompassing staff training initiative is regarded as one of the essential elements
contributing to the success of medication reconciliation.

5.1.4 Training should prioritize two fundamental aspects: the method of conducting patient
interviews to construct accurate and comprehensive best possible medication histories, and the
development of critical thinking skills needed for effective medication reconciliation(World
Health Organization, 2014).

5.1.5 The healthcare practitioner compares the collected medicines, allergies and ADR list against
the prescribed information, such as the medication chart, identifying and documenting any
discrepancies.

5.1.6 Adopt a standardised form for collecting pre-admission medicines and reconciling variances.

5.1.7 At each transition point all changes that have occurred to the patient’s medicines, allergies and
ADR list will be documented, dated, and communicated to ensure the care of the patient is
continued.

5.1.8 Establish specific time frames within which medicines should be reconciled for all patients (< 24
hours, within 4 hours for high-risk medicines) of admission, transfer, and discharge.

5.1.9 Provide clinicians ready access to drug information and a pharmacist consult when needed

Page 30 Maldives National Medication Standard Version 2, 2024

 5.1.10 Patients should comprehend the significance of engaging in medication
reconciliation by:

5.1.10.1 Maintaining an updated medication list or bringing their medications during hospital
admission, preadmission visits, or outpatient appointments, presenting this list to
healthcare providers during each encounter. This can be facilitated through educational
materials and tools designed to assist patients in independently managing their
medication lists. The Medication Reconciliation SOP Implementation Guide offers
examples of educational resources and tools to involve patients effectively

5.1.10.2 Advocating for themselves by voicing concerns if they suspect an error has occurred
with their medications.

5.1.11 When transferring a patient from one facility to another the following must be included with
the transfer documents

5.1.11.1 A copy of all current medication charts

5.1.11.2 A completed transfer summary with the key elements relating to medications that are
applicable to the discharge summary.

5.2 Criteria: Adverse drug reaction

5.2.1 The healthcare practitioner collects the most accurate list of medicines, allergies, and adverse
drug reactions (ADRs) using a minimum of two source types.

5.2.2 The healthcare practitioner must elicit, and document known medicine allergies and ADRs
experienced by a patient before their current admission.

5.2.3 Organizational policies, procedures, and guidelines on recording known medication allergies
must be available and up to date. These documents should:

Identify the healthcare practitioner responsible for recording information on known drug
allergies and ADRs. (Patients may be more familiar with the term allergy, than ADR, so this
may be a better prompt).
Provide a clear outline of information needed (for example, type of reaction, severity, and how
it was managed)
Describe where and when it is appropriate to record a known allergy or adverse reaction to
substances other than medicines, such as food, in the patient’s medicine allergy and ADR
history.

5.2.4 Provide orientation, training, and education to healthcare practitioners, and review the work
practices for:

Documenting known drug allergies and ADRs in the patient’s ADR history
Referring to a patient’s medicine allergy/ADR history before, or at the point of, decision-
making when prescribing, dispensing, or administering medicines.

5.2.5 Conduct audits of medicine allergies and ADRs and provide information to healthcare
practitioners through medication safety bulletins, in-service orientation sessions, case reports,
or grand rounds.

Maldives National Medication Standard Version 2, 2024 Page 31

Standard 6 : Professional responsibility and accountability

6.1 Criteria: Scope of practice

6.2 Criteria: Responsibility & Accountability
6.3 Medication Safety Committee & High-Risk Medicines Register
6.4 Nurturing Trusting Patient Relationships and Ensuring Safety

6.1 Criteria: Scope of practice

6.1.1 The healthcare service has processes to ensure that healthcare providers have the qualifications,
knowledge and skills required to perform their role by:

6.1.1.1 Describing the scope of clinical practice for healthcare providers

practicing in the healthcare service

6.1.1.2 Monitoring healthcare providers’ practices to ensure they are operating

within their designated scope of clinical practice.

6.1.1.3 Reviewing healthcare providers’ scope of clinical practice when a

clinical service, procedure or technology is introduced or substantially
altered.

6.2 Criteria: Responsibility & Accountability

Healthcare professionals must:

6.2.1 act within the law and adhere to Maldives Food and Drug Authority standards and professional
guidance when administering medicines to patients. It is expected that all nurses and midwives
have current nursing registration and licensing.

6.2.2 comply with local policies, protocols, guidelines and standards for high-risk medicines.

6.2.3 be knowledgeable about the therapeutic effects and side effects of the medication, its
interactions with food or other medications, and contraindications indication, mechanism of
action, dosage, precautions, and contraindications.

6.2.4 be knowledgeable about the medications they administer and those that their clients are
taking, whether prescribed, over the counter, or natural health products.

Page 32 Maldives National Medication Standard Version 2, 2024

 6.2.5 work together with individuals and/or their carers to prevent and/or manage risks, incidents
and adverse reactions associated with medicine use.

6.2.6 the knowledge, skill, and competence to recommend an appropriate over-the-counter

medication in accordance with employer requirements.

6.2.7 should recognize their level of competence in relation to medication administration and take
measures to develop their competence.

6.2.8 are expected to honor patients' rights and autonomy during the informed consent process,
acknowledging their right to refuse medication. The decision to withhold a medication may be
made by the nurse or midwife, guided by specific clinical rationale(s).

6.3 Nurturing Trusting Patient Relationships and Ensuring Safety

6.3.1 Healthcare professionals should establish and maintain trusting relationships with patients

6.3.2 Prompt reporting of any medication-related errors, whether actual or potential, is imperative.
Immediate corrective action must be taken.

6.3.3 Healthcare professionals should exercise professional judgment responsibly when asked to
disclose confidential information about patients or administered medications.

6.3.4 Honest and truthful information and guidance must be provided to patients, families, or legal
guardians. Communication should be tailored to the age and cognitive ability of the recipient.

6.3.5 In the event of an adverse occurrence, nurses and midwives are obligated to prioritize patient
safety. This involves promptly monitoring the patient's health status and taking necessary
actions to minimize or prevent further harm.

Maldives National Medication Standard Version 2, 2024 Page 33

Recommendations
Safe preparation, dispensing, storing & disposal of medication.
1. Medication errors are significantly influenced by similar-looking or sounding drug names, ambiguous
labels, and indistinct packaging. Implementing clear labeling and employing unit-dose systems in hospitals
can notably decrease the occurrence of these errors.

2. Healthcare organisations to develop no-interruption zone policy for safe preparation and administration of
medication.

3. Healthcare organisations ensure that specific recommendations for the safe procurement and storage of
anaesthetic medicines are included in any policies, procedures, or protocols, to minimise risks from these
medicines.

4. Evaluate the use and implementation of storage or delivery systems for safety, quality, and security risks.

5. Ensure that policies, procedures and protocols for safe handling, storage and distribution of medicines are
evidence based and comply with legislative requirements.

6. Perform audits of compliance with policies, procedures and protocols for handling, storage, and
distribution of medicines. Consider temperature-sensitive medicines and safety controls, such as separating
look-alike packaging or electronic alerts.

7. Develop guidance on effective processes to ensure the integrity of the cold chain that includes:

Audits of temperature control of storage facilities, including room temperature, refrigeration, and
frozen storage

Regular testing and maintenance schedules for temperature alarms and temperature recording
devices

Transportation or transfer of temperature-sensitive medicines between storage areas or facilities

Workforce orientation and training on cold chain management

Action required in the event of a cold chain breach or temperature excursion.

8. Install alarms to monitor refrigerators and cold rooms, as well as medicine storage areas (including
pharmacy departments), where temperatures would ideally be maintained below 25 °C (according to the
manufacturer’s instructions)

9. Health services ensures ADR Alert stickers are available.

10. Establish systems for identifying, reporting, and learning from medicines-related patient safety incidents.

Organisations should support a person-centred, 'fair blame' culture that encourages reporting and
learning from medicines-related patient safety incidents.

Health care practitioners should explain to patients, and their family members or carers where
appropriate, how to identify and report medicines-related patient safety incidents.

Page 34 Maldives National Medication Standard Version 2, 2024

Medication reconciliation:

11. In an hospital setting, accurately list all the person's medicines (including prescribed, over-the-counter and
complementary medicines) and carry out medicine’s reconciliation within 24 hours or sooner if clinically
necessary, when the person moves from one care setting to another – for example, if they are admitted to
hospital.

12. All health care settings should ensure that a designated healthcare professional has overall organisational
responsibility for the medicine’s reconciliation process. The process should be determined locally and
include:
organisational responsibilities

responsibilities of healthcare practitioners involved in the process (including who they are
accountable to)

individual training and competency needs.

13. Organisations should ensure that medicines reconciliation is carried out by a trained and competent
health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary
knowledge, skills and expertise including:
a. effective communication skills
b. technical knowledge of processes for managing medicines
c. therapeutic knowledge of medicines uses.
14. Health Clinics or small hospitals that are part of a local health network or private hospital group
should adopt or adapt and use the established process for documenting a patient’s history of
medicine allergies and ADRs, as a component of past medical history.

15. In outpatients’ departments (OPD) or clinics, healthcare professionals must elicitelicit, and
document known medicine allergies and ADRs experienced by a patient before their admission.

16. Organisations should consider involving a pharmacist with relevant clinical knowledge and skills
when making strategic decisions about medicines use or when developing care pathways that
involve medicines use.

17. Ministry of Health to develop a tool kit that provide information, resources and quality
improvement (QI) tools for managers and clinicians to improve Med Rec in health services.

18. Ministry of Health to collate a High-Risk Medication Register.

Maldives National Medication Standard Version 2, 2024 Page 35

Partnering with Patients
19. Support people to be partners in their own care by promoting shared decision making, improving health
literacy, and developing information about safety and quality for patients and patients, particularly for
people with vulnerabilities.

20. Communicate with patients in a way that supports effective partnerships and shared decision making, to
the extent that the patient chooses.

21. Patients can play a vital role in preventing medication errors when they have been encouraged to ask
questions and seek answers about their medications.

Documentation
22. National standard medication charts should be introduced to healthcare facilities to improve the safe use
of medicines. The charts support the delivery of appropriate care for hospitalised patients to help
communicate information consistently between clinicians on the intended use of medicines for an
individual patient.

23. National standard medication charts can be adapted into different versions for adults

24. Healthcare professionals are advised to use clinical discretion and consideration of the circumstances for
individual patients when using the charts for patient medication management in acute care settings.

Page 36 Maldives National Medication Standard Version 2, 2024

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