MOM - GAP analysis






1.     MANAGEMENT OF MEDICATION (MOM)
Total chapters
: 10

MOM1
: Documented policies and procedures guide the organization of pharmacy services and usage of medication

MOM 2
: There is a hospital formulary

MOM 3
: Documented policies and procedures exists for storage of medication

MOM 4
: Documented policies and procedures exists for prescription of medication

MOM 5
: Documented policies and procedures guide the safe dispensing of medications

MOM 6
: There are defined procedures for medication management

MOM 7
: Patients are monitored after medication administration

MOM 8
:  Near misses, medication errors and adverse drug events are reported and analysed

MOM 9
: Documented policies and procedures guide the use of medical supplies and consumables

MOM 10
Documented policies and procedures guide the use of formulations containing toxic / narcotic drugs

Score oo
: 14

Score 05
: 19

Score 10
: 17

Average score
: 4.81

MOM 10
: Not Applicable






Gap
 Time


1
  MOM 1 a:       
There is no pharmacy medication usage manual. Currently scattered data is available
short


2
  MOM 1. c:
 Pharmacy advisory board should be reconstructed with including a trained pharmacist
short


3
 MOM 1. d
Currently pharmacy works from 8 am to 8 pm. So an SOP for essential medication arrangement round the clock should be made.
short


4
 MOM 2. a:
 Need to prepare an organizational formulary based on Essential Drug List
short


5
  MOM 2. c:
Need to provide a complete available medicine list for the reference of clinicians.
short


6
  MOM 2. e
SOP for production of medicine is not fully incorporated. Guidelines for preparation of panchakarma therapy and production should be documented.
short


7
  MOM 3. a:
Improvement in hygiene in storage of medication is needed. A review committee shall be constructed
short


8
 MOM 3. c:
Storage of medicine according to inventory practices should be implemented.
short


9
 MOM 3. d:
An organizational storage system for medication attached to the hospital is necessary.
short


10
  MOM 4. a:
Training for medicine dispensing and prescription (in block letters).
short


11
 MOM 4. b
List of high alert medication (rasa preparation / visha) should be prepared.
short


12
 MOM 5. c
In house training required for pharmacist for dispensing medicines.
short


13
  MOM 5. d
Proper labelling of dispensing packs should be implemented.
short


14
  MOM 6. b:
Training for therapist, internees and PG Scholars implementing SOP for procedures.
short


15
MOM 6. c
Documentation is needed before the administration of high alert medications.
short


16
  MOM 6.
Training to duty nurses for proper checking and administration of self-medication by patients.
short


17
 MOM 7
Documentation for ADR is required.
short




1
 MOM 1. a
Construction of pharmacy medication / usage manual.
long


2
MOM 3. a
Improvements in hygiene and facilities of storage attached to hospital.
long


3
  MOM 1. b
Presently no GMP certification for pharmacy existing. Initiations for acquiring GMP and drug licensing should be done.
long


4
MOM 3. a
Storage Facility currently not available in hospital. recommended specification should be meat in infrastructure.
long







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