NABH 6th Edition MOM Chapter: Management of Medication Explained

What the MOM chapter is about

NABH's intent for MOM is a safe, organised medication process, governed by written guidance from purchase to the patient. The hospital designates a medication safety officer, keeps a formulary, gives the pharmacy oversight of every medicine stocked outside it, and standardises emergency medicines across the hospital. NABH also states that medications include blood, implants and devices.

Core elements are checked at every assessment and every Core element must score at least 4 out of 5. Our 6th Edition overview explains the scoring.

The 11 standards at a glance

Pharmacy oversight and the formulary (MOM.1–MOM.2)

MOM.1 needs written guidance for pharmacy services, a multidisciplinary committee that guides them, a procedure for getting medicines when the pharmacy is closed or out of stock, and a way to tell staff about key changes. Updating the processes is an Achievement element.

MOM.2 makes the formulary a Core element: a list of medicines suited to your patients and services, developed by the multidisciplinary committee (MOM.2.a). The committee reviews it at least once a year, clinicians can consult the current version, and there are procedures for buying formulary medicines and for getting medicines that are not on it. Clinicians actually following the formulary is an Achievement element.

Evidence that works: pharmacy and therapeutics committee terms and minutes; a dated formulary with its annual review; a non-formulary request form with records; an after-hours and stock-out procedure.

Storage, high-risk and emergency medicines (MOM.3)

This standard carries four Core elements, and it is where assessors find the most gaps:

• MOM.3.a (Core): clean, safe and secure storage that follows the manufacturer's recommendations, including temperature and light.
• MOM.3.c (Core): a defined and updated list of high-risk medications.
• MOM.3.e (Core): high-risk medicines, including look-alike, sound-alike medicines and different concentrations of the same medicine, stored physically apart.
• MOM.3.g (Core): emergency medicines available at all times and replenished promptly after use.

The list of emergency medicines must also be defined and stored the same way everywhere (MOM.3.f). Keeping high-risk medicines only where clinically needed is an Achievement element.

Evidence that works: temperature logs for medicine refrigerators and stores; a high-risk medication list displayed in the pharmacy and wards; separate, labelled storage for look-alike, sound-alike drugs and concentrated electrolytes; a standard emergency trolley list with check and replenishment records.

Prescribing and medication orders (MOM.4–MOM.5)

MOM.4 sets three Core elements: the hospital's minimum requirements of a prescription are followed (MOM.4.b), medication reconciliation happens at transition points such as admission, transfer and discharge (MOM.4.e), and verbal orders are handled with safe practices (MOM.4.f). Prescribers must check allergies and previous adverse reactions. Auditing prescriptions and acting on the findings are Achievement elements, and a mechanism that assists clinicians in prescribing, such as decision support, is the chapter's only Excellence element.

MOM.5 asks for uniform orders: written only by authorised staff, in a fixed place in the record with the patient's name and unique ID, legible, dated, timed and signed, and stating the medicine, route, strength and frequency or time.

Evidence that works: a prescription policy stating the minimum content; reconciliation forms in admission, transfer and discharge files; a verbal order policy with read-back and countersignature; monthly prescription audits.

Dispensing and administration (MOM.6–MOM.7)

Dispensed medicines must be labelled (MOM.6.d, Core) and high-risk orders verified before dispensing (MOM.6.e, Core). The pharmacy also needs procedures for recalls, near-expiry stock and returns.

At the bedside, the medicine is verified against the order and physically inspected before administration (MOM.7.d, Core), and measures prevent catheter and tubing misconnections (MOM.7.h, Core). The other elements cover who may administer, labelling a prepared drug before preparing the next, identifying the patient, checking strength, route and timing, documenting administration, and rules for self-administration and medicines patients bring from home.

Evidence that works: pharmacy labels with patient details; a high-risk order verification log; nurses who can explain their administration checks; medication administration records; a policy on patients' own medicines.

Monitoring, errors and adverse reactions (MOM.8)

Patients are monitored after administration and treatment is changed where monitoring shows a need. The Core element is capturing near misses, medication errors and adverse drug reactions (MOM.8.c). They are reported within a defined time, collected, analysed and acted upon. Two of the 6th Edition's hospital-wide quality indicators measure the same events: incidence of medication errors and in-patients developing adverse drug reactions; see the NABH quality indicators list.

Evidence that works: an incident reporting system that staff actually use, with near misses; adverse drug reaction forms; monthly analysis in committee minutes; corrective actions with follow-up.

High-risk drugs, implants and supplies (MOM.9–MOM.11)

MOM.9 covers narcotics and psychotropic substances, chemotherapy and radiopharmaceuticals: prescribed by appropriate caregivers, stored securely, prepared safely, given by qualified staff, and recorded through use, administration and disposal.

MOM.10 requires implants and medical devices to be used against scientific criteria and recognised guidelines or approvals, with patient counselling. The batch and serial number of every implant goes into the patient's record, the master logbook and the discharge summary. Handling implant recalls is an Achievement element.

MOM.11 applies the same storage, inventory and condition checks to medical supplies and consumables.

Evidence that works: a narcotic register with balances and two-person checks; chemotherapy preparation records; an implant register; stickers or entries showing batch and serial numbers in discharge summaries.

How assessors test MOM

Assessors follow a patient's medicines. They read the prescription and the chart, ask the nurse how she checks a drug before giving it, look for the reconciliation form, open the emergency trolley and check its list and expiry dates, and inspect high-risk and look-alike, sound-alike storage on the ward. In the pharmacy they ask for the formulary, the high-risk list, recall and near-expiry records, and the medication error reports. A hospital with no reported errors usually has a reporting problem, not a perfect record.

Getting MOM ready

1. Map all 68 elements and fix the 13 Core elements first.
2. Set up or revive the pharmacy and therapeutics committee, the formulary and the high-risk list.
3. Reorganise storage: separate look-alike, sound-alike drugs and concentrations, and standardise every emergency trolley.
4. Train doctors and nurses on prescriptions, verbal orders, reconciliation and administration checks.
5. Start reporting near misses and errors, and review them monthly.

Our NABH documents checklist lists the MOM policies, and we run 6th Edition gap analyses scored the way assessors score. Hospitals up to 50 beds follow the equivalent chapter in the SHCO standards.

All ten NABH 6th Edition chapter guides: AAC · COP · MOM · PRE · IPC · PSQ · ROM · FMS · HRM · IMS