BRSH/MOM/24/01

DOCUMENT NAME: POLICY ON MEDICATION

ADMINSTRATION

REFERENCE BY NABH 5TH EDITION

1.0 PURPOSE AND SCOPE

1. To provide uniform guidelines for safe preparation, administration and documentation of

medications.
2. To ensure adequate patient monitoring and detection of occurring undesirable side effects
follows medication administration.

2.0 POLICY STATEMENT

1) Medication shall be administered by a qualified registered nurse /adequately supervised

trainee Nurse or Nursing student by Registered Nurse only upon a WRITTEN physician’s
order.
2) Self administration of medication by patient is allowed only in supervision of Registered
nurse/Physician for specific cases

3.0 TARGET AUDIENCE: Nursing, Medical Admin & Pharmacy

4.0 RESPONSBILITY

All qualified registered nurses, and adequately supervised nursing trainee nurse / students are
responsible for:

1. Assessing the patient’s need for medications, their indications and contraindications.
2. Being knowledgeable about medications contraindications, side effects and antidotes
(when applicable)
3. Verifying adequacy and completeness of physicians’ medication orders .
4. Preparing the resources and the patient for administering medications.
5. Administering medications properly and safely to the patients.
6. Documentation of administered medications.
7. All the physicians and residents are responsible for providing safe, clear and complete
medication orders.
8. verbal orders for administration of medication can be accepted as per verbal order
policy
9. Nurses are responsible for proper Indenting, storage, administration and documentation of
High-Alert and High-Risk medication.

Issue No.: 01 Issue Date: 01.04.2024 Revision No: N/A

Effective Date:01.04.2024 Revision Date: -N/A
Doc. Prepared By: Doc Reviewed By: Doc. Approved By:
Mr. SUNNY
Mr. MANISH JAIN Dr. AMIT SHASTRI Page 1 of 5
 BRSH/MOM/24/01
DOCUMENT NAME: POLICY ON MEDICATION
ADMINSTRATION

REFERENCE BY NABH 5TH EDITION

5.0 PROCEDURE

PATIENT ASSESSMENT

1. Assess the patient for indication and contraindication for patient taking medication.
2. Check the patient’s vital signs

3. Review the patient’s medical history, history of allergic medication, diet history, and
laboratory findings that may influence medication administration.

4. Review current medications and identify possible interactions or incompatibilities.

5. Assess patient’s know ledge regarding medication usage, its indications and side effects.

ORDER VERIFICATION

1. Check the accuracy, completeness of physician’s written medication orders on medication

chart which should include the medication’s name, dosage, administration route,
frequency and dilation.

2. Make sure that the physician’s medication order is well written his/her clinical notes.
3. Obtain medication order renewal from patient’s physician for the extended use
drugs.

INDENTING AND GETTING OF MEDICATION

1. After verification of order, indent the correct medication in correct dosage to

Correct patient.

2. After getting medication from pharmacy, verify that the medication dispensed is
correct regarding dosage form, quantity as per bill, in-appropriateness like damage
or color change in medications, expiry.
3. Inappropriate medications shall be returned to the pharmacy.

PREPARATION
Issue No.: 01 Issue Date: 01.04.2024 Revision No: N/A
Effective Date:01.04.2024 Revision Date: -N/A
Doc. Prepared By: Doc Reviewed By: Doc. Approved By:
Mr. SUNNY
Mr. MANISH JAIN Dr. AMIT SHASTRI Page 2 of 5
 BRSH/MOM/24/01
DOCUMENT NAME: POLICY ON MEDICATION
ADMINSTRATION

REFERENCE BY NABH 5TH EDITION

1. Perform hand hygiene.

2. Assure good lighting and absence of distractions and interruptions.
3. Prepare the medications for one patient at a time. Keep the Patient file around while
preparation.

4. Select the correct medication from the patient’s medication drawer.

5. Be aware of look alike and sound-alike medications.

6. Check twice the correctness of medication and dosage form from patients file
(medication chart).
7. Calculate medication dose as necessary.
8. Check the medications’ expiry dates, stability, consistency, discoloration and
compatibility with other medications.
9. Label the medications with the patient’s name, UHID number, medication name dose,
route, date and time of preparation prior to preparation of second medication.

10. Compare record with the prepared medications.

11. Refrigerate medication, if recommended.

DO NOT LEAVE MEDICATIONS UNATTENDED and unlabelled.

CARE FULLY REVIEWS MEDICATION CHART TO ENSURE THE “SEVEN

RIGHTS”:

1. Right Drug
2. Right Dose
3. Right time
4. Right route
5. Right patient
6. Right purpose
7. Right documentation

CHECK THREE TIMES THE MEDICATION LABEL:

1. When reaching for the container or the unit dose package

2. Immediately before pouring or opening the medication
Issue No.: 01 Issue Date: 01.04.2024 Revision No: N/A
Effective Date:01.04.2024 Revision Date: -N/A
Doc. Prepared By: Doc Reviewed By: Doc. Approved By:
Mr. SUNNY
Mr. MANISH JAIN Dr. AMIT SHASTRI Page 3 of 5
 BRSH/MOM/24/01
DOCUMENT NAME: POLICY ON MEDICATION
ADMINSTRATION

REFERENCE BY NABH 5TH EDITION

3. When replacing the container to the drawer or shelf or before giving the medication
to the patient.

MEDICATIONS ADMINISTRATION

1. Keep the patient file together while administering medication.

2. Take the correct medication to the correct patient at the correct prescribe bed time
(allowed timeframe for medication or after their administration is One hour prior
scheduled timing for up to OD, BD, TDS, QID ,for more administration allowed
variation in timeframe is 30 minutes and 10 minutes for one hourly).
3. Identify the correct patient by comparing full name on Medical records with name on
patient’s UHID numbers , by Patient name on patient band.
4. Explain to patient or his family, the purpose, intended effect and side effect of each new
medication before administering it and reply to the patient’s questions about the
medication.

5. Assist the patient to sitting position if possible.

6. Administer medication properly.
7. Stay at the patient’s bedside until he has taken ALL of his/her medications.
8. Assist the patient in returning to a comfortable position.
9. Dispose of soiled supplies properly.
10. Perform hand hygiene after administration of medications especially for other than oral.

DOCUMENTATION OF MEDICATION ADMINISTERED

1. Document immediately after the medication administration on medication

chart,time of administration with nurse name (in block letter) & signature and
employee id.
2. Mention it on nursing progress sheet also for time, dosage, and duration of
infusion.

6.0 DEFINITION AND ABBREVIATION

Registered Nurse: - Nurses having minimum qualification for nursing practice by

recognized/approved institution by nursing council of India (NCI), UGC/AICTE and
registered from nursing council of India and RNC for practicing as a Nurse in Jindal
Issue No.: 01 Issue Date: 01.04.2024 Revision No: N/A
Effective Date:01.04.2024 Revision Date: -N/A
Doc. Prepared By: Doc Reviewed By: Doc. Approved By:
Mr. SUNNY
Mr. MANISH JAIN Dr. AMIT SHASTRI Page 4 of 5
 BRSH/MOM/24/01
DOCUMENT NAME: POLICY ON MEDICATION
ADMINSTRATION

REFERENCE BY NABH 5TH EDITION

Hospital.

IPSG: International Patient safety Goals

7.0 CROSS REFERENCE / POLICY / FORMS AND RECORDS

Drug Chart Nursing progress sheet nursing records

Issue No.: 01 Issue Date: 01.04.2024 Revision No: N/A

Effective Date:01.04.2024 Revision Date: -N/A
Doc. Prepared By: Doc Reviewed By: Doc. Approved By:
Mr. SUNNY
Mr. MANISH JAIN Dr. AMIT SHASTRI Page 5 of 5