Friday, July 2, 2010

MESAC promotes medication safety via medication manual

Medication manual experts: From left, Kelly Barnes, RPh, compliance pharmacist; Alioto; Empoliti; Romeena Lee, project coordinator; and Tully

Medication safety is one of the highest priorities at the MGH. To effectively promote and enhance medication education, safety and distribution, the Medication Education Safety and Approval Committee (MESAC) was launched in 2004 under the auspices of the Medical Policy Committee. A multidisciplinary group comprising representatives from across the hospital, including Pharmacy, Nursing, Compliance and the Center for Quality and Safety, MESAC recently completed a milestone project, the transition of the medication manual -- which includes all medication-related policies, guidelines and procedures at the MGH -- to TROVE, the online repository of MGH policies and procedures.

"We are thrilled to have reached the July 1 launch of the transition to TROVE," says Margaret Clapp, RPh, chief pharmacy officer. "The move provides users with a single, easily available, up-to-date, consistent source for all medication-related policies, procedures and guidelines. The transition also will greatly support medication practices, the medication management process and will help the hospital meet certain regulatory medication requirements."

Of the two-year project, Susan Tully, RN, MESAC Executive Committee member and nursing director of Ellison 4, adds: "The initial challenge was to identify existing medication-related documents throughout the hospital. Each document was then reviewed and updated to ensure it reflected current best practices and regulatory requirements consistent with policies, procedures and guidelines at the MGH. MESAC then reviewed and approved these documents. The final step in the process took place July 1 when all of these documents were moved to TROVE."

The Medication Manual can be accessed in TROVE under Policy and Procedure Manuals and consists of the following folder sections:

  • General Policies and Procedures
  • Medication-Specific Policies and Procedures -- previously located in the Nursing Procedure Manual 

 Medication Guidelines, previously located in the MGH IV Medication Reference and Nursing Procedure Manual, is divided into the following four groups:

  • Adult Critical Care
  • Adult General Care
  • Pediatric Critical Care
  • Pediatric General Care  
For more information on how to submit a medication-related document for the Medication Manual in TROVE, contact Dena Alioto, RPh, pharmacy compliance director, at; Tully at; or Joanne Empoliti, MSN, RN, APRN, BC, clinical nurse specialist, at For more information about MESAC, contact Christopher Coley, MD, chair of MESAC, at

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