Table Of Contentइंटरनेट मानक
Disclosure to Promote the Right To Information
Whereas the Parliament of India has set out to provide a practical regime of right to
information for citizens to secure access to information under the control of public authorities,
in order to promote transparency and accountability in the working of every public authority,
and whereas the attached publication of the Bureau of Indian Standards is of particular interest
to the public, particularly disadvantaged communities and those engaged in the pursuit of
education and knowledge, the attached public safety standard is made available to promote the
timely dissemination of this information in an accurate manner to the public.
“जान1 का अ+धकार, जी1 का अ+धकार” “प0रा1 को छोड न’ 5 तरफ”
Mazdoor Kisan Shakti Sangathan Jawaharlal Nehru
“The Right to Information, The Right to Live” “Step Out From the Old to the New”
IS 15784 (2007): Healthcare facilities - Particular
requiremennts [MHD 14: Hospital Planning]
“!ान $ एक न’ भारत का +नम-ण”
Satyanarayan Gangaram Pitroda
““IInnvveenntt aa NNeeww IInnddiiaa UUssiinngg KKnnoowwlleeddggee””
“!ान एक ऐसा खजाना > जो कभी च0राया नहB जा सकता हहहहै””ै”
Bhartṛhari—Nītiśatakam
“Knowledge is such a treasure which cannot be stolen”
IS 15784: 2007
Indian Standard
HEALTHCARE FACILITIES - PARTICULAR
REQUIREMENTS
res 11.020
© BIS 2007
BUREAU OF INDIAN STANDARDS
MANAK BHAVAN, 9 BAHADUR SHAH ZAFAR MARG
NEW DELHI 110002
September 2007 PriceGroup7
Hospital Planning Sectional Committee.MHR 14
FOREWORD
This Indian Standard was adopted by the Bureau ofIndian Standards. after the draft finalized by the Hospital
PlanningSectionalCommitteehadbeenapproved bytheMedical Equipmentand Hospital PlanningDivisionCouncil.
Thisisthe formal recognition by the community ofthe socialstructure of a country and its responsibility for
providing the means for keepingthem well or restoring lost health.The healthcarefacilitieshasbeendefinedas
an integral part ofa social and medical organization. the function of which is to provide complete healthcare
(bothcurative andpreventive)tothepopulationand whoseoutpatientservicesreach outtothe family initshome
environment,The healthcarefacilitiesare alsoacentrefor the trainingofhealth workersand bio-socialresearch.
Thisdefinitionholds true for big as well assmallhospitals. It visualizes the healthcare facilities asone part ofa
comprehensivesystem ofpreventiveand curative medicine and as an institution devoted not only to in-patient
treatmentbutalso toambulatory and domiciliarycare.
In therecent past.there has been a mushrooming growth ofsubstandard hospitals and nursing homes in India
which necessitated the need ofreviewofposition inthis regard and put forward suggestions for improving the
quality ofhealthcare throughstandardization and accreditation ofhealthcare facilities.The situation. in fact. is
even worse as these healthcare facilities and beds are distributed irrationally in different areas ofthe country.
Whatistechnicallycalled'LicensingofHospitals'islackingaltogetherin India.Every healthcarefacilityhasits
ownstructuralplan with the resultthatqualityassuranceofmedical care is not inevidence.
This necessitatedinthe developmentofthis standard.Thisstandard isenvisaged to provideanationalsystem of
healthcare to common mankind. Healthcare facilities faithfully mirror the level of a nation's development.
Healthcarefacilitiescan beclassified into various types based on differentcriteria.Thisstandard is intendedto
cater tothe needs ofsecondaryand tertiary level. healthcare facilities. speciality and superspeciality hospitals.
While nothing prevents its application to other areas like nursing homes. paramedical services, etc. it is likely
that these may also form our future projectsspecifyingspecific needs to particularapplication.
This standard on healthcare facilities covers guidelines on access. assessment and continuity ofcare. patient
rights and education. careofpatient. managementofmedication. hospital infection control.continuousquality
improvement. responsibility of management. facility management and safety. human resource management,
information managementsystemofhealthcare facilities.
The otherstandardspublishedon the subject,which couldalso be relevant.are given inAnnexA.
The Composition ofcommitteeresponsible for the formulation ofthisstandard is given inAnnex B.
,
IS 15784:2007
Indian Standard
HEALTHCARE FACILITIES - PARTICULAR
REQUIREMENTS
1SCOPE life-stabilizing treatment and be then either admitted
(ifresourcesareavailable)ortransferredappropriately
This standard covers the essential requirements for
toanotherhealthcarefacilitythat has theresourcesto
healthcare facilities, secondary and tertiary level,
take care ofsuch patients. Patients shall beaccepted
specialityand superspeciality hospitals.
onlyifthehealthcarefacility can provide therequired
2REFERENCES service. There shall be policies and procedures for
managingpatientsduring non-availabilityofbeds.The
The following standards contain provisions, which
staffshall be aware ofthese processes.
through reference in this text, constituteprovisions of
this standard. At the time of publication, the editions 3.3 Healthcare facilities shall have an appropriate
indicatedwerevalid.Allstandardsaresubjecttorevision mechanismfortransferorreferralofthos»patientswho
and parties to agreement based on this standard are can not be treated there. There shall be policies and
encouraged toinvestigatethepossibilityofapplyingthe procedures for the transfer of stable and unstable
mostrecenteditionsofthestandardsindicated below: patients to other appropriate healthcare facility and
detailedproceduresidentifyingstaffresponsibleduring
ISNo. 1itle
transfer.Thehealthcarefacilities shallgiveasummary
12433 Basic requirements for hospital
of patient's condition. investigation reports and the
planning:
treatment given atthetimeoftransfer/referraltoother
(Part I): 1988 Up to3D-bedded hospitals healthcare facilities.
(Part2): 1988 Up to lOO-beddedhospitals
ISIISO 1400I : Environmental management 3.4 During admission the patient and/or the family
2004 systems - Requirements with membersshallbeeducated tomakeinformeddecisions.
guidance foruse It shall be ensured that the patients and/or family
ISIISO 15189: Medical laboratory - Particular members are explained about the proposed care,
2003 requirements for quality and expectedresults,possiblecomplicationsandexpected
competence costs inalanguagethatcan beunderstood bythem.
15195:2002 Performance guidelines for quality 3.5Patients cared forby thehealthcare facilitiesshall
assurance in hospital services up to undergo an established initial assessment. The
3D-bedded hospitals hcalthcare facilities shall define the content of the
15461:2004 Performance guidelines for quality assessments, time frame for completion of initial
assurance in hospital services up to assessment & personnel who shall carry out these
100-beddedhospitals assessments.
18001:2007 Occupational health and safety
management systems 3.5.1 The initial assessment for in-patients shall be
Requirements documented within 24 hOfearlierasper the patient's
condition or hospital policy including screening for
3ACCESS,ASSESSMENTANDCONTINUITYOF nutritionalneeds.The initial assessmentshallresultin
CARE adocumented planofcare,which includes preventive
aspects ofthecare.
3.1Patientsshall bewell informedoftheservicesthat
the healthcare facility can and cannot provide. This 3.6 All patientscaredfor byhealthcarefacilities shall
willfacilitate inappropriately matchingpatientswith undergo regular reassessment. All patients shall be
the healthcare facility's resources. The healthcare reassessed at appropriate intervals as per the need to
facilities clearly define and prominently display the determine their response to treatment and to plan
servicesthat itcan provideand thestaffisorientedto further treatmentordischarge.Staffinvolvedindirect
theseservices(seealso 4.4). clinical care shall documentall reassessments.
3.2The healthcarefacilitiesshall have awell-defined 3.7 Laboratory services shall be provided as per the
registrationand admission process with standardized requirementsofthe patients. Scope ofthe laboratory
policiesandproceduresforoutpatients.in-patie ntsand services shall be commensurate with the services
emergency patients.Emergency patientsshall receive provided by the healthcare facilities and adequately
IS15784:2007
qualified and trained personnel perform and/or Imaging personnelshall be providedwithappropriate
supervisetheinvestigations.Thereshallbepoliciesand radiation safety devices. which shall be periodically
procedurestoguidecollection,identification,handling, tested and documented.Personnel shall be trained in
safe transportation, processing and disposal of radiation safety measures. The imaging signageshall
specimens. The laboratory results shall be available beprominentlydisplayed inallappropriatelocations.
withinadefined time frame and critical results shall Policies and procedures shall guide the safe use of
beintimatedimmediately totheconcernedpersonnel. radioactive isotopesfor imagingservices.
Howeverlaboratorytestsnotavailableinthehealthcare
3.9Duringallphasesofcare, thereshallbeanidentified
facilities shall be outsourced to other healthcare
qualified person responsible for the patient. Care of
facilitiesbasedontheirquality assurancesystem.
patientshall becoordinated inall care settingswithin
3.7.1 There shall be a documented established thehealthcarefacilities. Informationaboutthepatient's
laboratory quality assurance programme (see care and response to treatmentshall beshared among
ISIISO 15189). This programme shall address medical, nursing and other care providers. The
verificationandvalidationoftestmethods,surveillance informationshallbeexchangedanddocumentedduring
oftestresults,periodiccalibrationandmaintenanceof each staffingshift,betweenshifts andduring transfers
allequipments withdocumentation of corrective and between units/departments.Patient'srecord(s)shallbe
preventiveactions. available tothe authorized care providersto facilitate
the exchangeofinformation.
3.7.2 There shall be a documented established
laboratory safety programme. This programme shall 3.10The healthcarefacilitiesshall haveadocumented
beintegrated with the healthcare facility's safety dischargeprocessandeach patient'sdischargeprocess
programme. Written policies and procedures shall shall be planned. Policies and procedures shall exist
guide the handling and disposal of infectious and forcoordinationofvariousdepartmentsand agencies
hazardousmaterials.Further thelaboratory personnel involved inthe discharge process (including medico
shallbeappropriatelytrainedinsafepracticesandshall legal cases). Policies shall be in place for patients
beprovidedwithappropriatesafetyequipment/devices. leaving againstmedicaladvice.Adischargesummary
shall begiven toallthe patientsleavingthehealthcare
3.8 Imaging services shall be provided as per the
facility (including patients leaving against medical
requirementsofthepatientsandshallcomplywithlegal
advice).
and other requirements. The scope of the imaging
services shall be commensurate with the services 3.10.1 Healthcarefacilitiesshall define thecontentof
provided by the healthcare facilities. Adequately thedischargesummary,which shall beprovidedtothe
qualified and trained personnel shall perform and/or patientsatthetimeofdischarge.Thisshallcontainthe
superviseandinterpret theinvestigations. reasons foradmission.significantfindings, diagnosis,
the patient's condition at the time of discharge,
3.8.1 Policies and procedures shall guide the
information regarding investigation results. any
identification and safe transportation of patients to
procedure performed, medication, other treatment
imaging services. Imaging results shall be available
given and the name ofthe treatingdoctor. Discharge
withinadefined timeframe.However.critical results
summary shall contain follow-up advice, medication
shall be intimated immediately to the concerned
andotherinstructions inanunderstandablemannerand
personnel.Thoseimagingtests,whicharenotavailable
incorporateinstructionsaboutwhenandhowtoobtain
inthehealthcarefacilities,shallbeoutsourcedtoother
urgent care.
healthcare facility based on their quality assurance
system. 3.10.2Incase ofdeath,the summaryofthecase shall
also include the cause ofdeath and may be given to
3.8.2Thereshallbeadocumentedestablishedquality
the nextofkinon demand.
assurance programme for imaging services. This
programmeshalladdresstheverificationandvalidation 3.10.3The patientrecordsshallcontainacopy ofthe
of imaging methods, surveillanceof imaging results, discharge/case summary.
periodiccalibrationandmaintenanceofallequipments
with documentation of corrective and preventive 4 PATIENT'SRIGHTSANDEDUCATION
actions.
4.1Patientandfamily rightssupportindividualbeliefs,
3.8.3Thereshallbeadocumentedestablishedradiation values and involve the patientand family indecision
safetyprogramme.Thisprogrammeshallbeintegrated making processes. These shall include respect for
withthehealthcarefacility'ssafetyprogramme.Written personal dignity and privacy during examination,
policies and procedures shall guide the handling and procedures and treatment, protection from physical
disposal of radioactive and hazardous materials. abuse or neglect. treating patient information as
2
IS 15784:2007
confidential. refusal of treatment. informed consent 5.1.1 The care and treatment orders shall besigned.
before anesthesia. blood and blood product named, timed anddated by theconcerneddoctorand
transfusions and any invasive/high risk procedures/ care plan shall hecountersigned by the clinician in
treatment. Patient and family rights shall include charge of the patient within 24 h. Evidence based
informationand consentbeforeanyresearchprotocol medicine and clinical practice guidelines shall be
is initiated and information on how to voice a adopted forpatient care whereveravailable.
complaint. It shall also include the expected cost of
5.2 Emergency services shall beguided by policies.
thetreatment andaccessto his/herclinicalrecords.
procedures and applicable laws and regulations and
4.1.1 The healthcare facilities shall protect patient's shallhedocumented.Theseshallalsoaddresshandling
and family's rights duringcare.These rightsshall be ofmedico-legalcasesandthepatientsshallreceivecare
documentedandcommunicatedtopatientsandfamilies in consonance with the policies. Policies and
inaformatand language thatthey canunderstand. procedures shall guide the triage of patients for
appropriatecare.Thestaffshallbetrainedandfamiliar
4.1.2 The healthcare facility's leaders shall protect
withthepoliciesand proceduresforcareofemergency
patient's and family's rights.The staffshallbe aware
patients.Allthepatientswhoareadmitted.discharged
of their responsibility in protecting these rights.
or transferred to other healthcare facility shall be
Violationofpatientand familyrightsshallberecorded.
documented.
reviewed and corrective/preventive measurestaken.
5.3 The ambulance services shall be commensurate
4.2Thereshall beadocumented processforobtaining
with the scope of the services provided by the
patient and/orfamily'sconsent forinformeddecision
healthcarefacilities.Thereshallheadequateaccessand
making.abouttheircare.Thisshallalsoincludegeneral
space for the ambulance(s). These shall be
consent atthe time ofpatient'sadmission.
appropriately equipped and manned by the trained
Patient and/or his family members shall be informed personnel.
ofthe scopeofsuch general consent. The healthcare
5.3.1 Thereshall beachecklistof all the equipments
facilities shall list those situations where informed
and emergency medications. Equipments shall be
consent is required. Informed consent shall include
checkedonadailybasis.Emergencymedicationsshall
information on risks, benefits, alternatives and as to
be checked daily and prior to dispatch. The
whowillperform therequisiteprocedure.inalanguage
ambulance(s) shall have a proper communication
thattheycan understand.Thepolicyshalldescribewho
system
can give consent when patient is incapable of
independentdecision-making. 5.4Thereshallbedocumentedpoliciesandprocedures
for the care of patients requiring cardio-pulmonary
4.3 Patients and families shall have a right to
resuscitation. These policies and proceduresshall be
informationandeducationabouttheirhealthcareneeds
used uniformly throughout the healthcarefacility.
inalanguageand manner that isunderstood by them.
5.4.1 Allthestaffprovidingpatientcareshallbetrained
4.3.1 This shall includeeducation about the safe and
and periodically updated in cardio-pulmonary
effective use of medication and their potential side
resuscitation. The events during a cardio-pulmonary
effects;diet and nutritionand immunizations.
resuscitation shall be recorded.
4.3.2 These shall also include education about their
5.4.2Apost-event analysis ofall cardiacarrests shall
specificdisease process,complicationsand prevention
bedone bya multidisciplinarycommittee.Corrective
strategies.aboutpreventing infectionsand shall be in
and preventive measures shall betaken based on the
alanguageand format that they can understand.
post-event analysis
4.4Patientandfamiliesshallhavearighttoinformation
5.5Thereshallbedocumentedpoliciesandprocedures
on expected costs. There shall bea uniform pricing
todefine rationaluseofblood andblood products.The
policyinagivensetting(outpatientandwardcategory).
applicable laws and regulations shall govern the
The tarifflist shall bemadeavailable to the patient's
transfusionservices.Theconsentshallbeobtainedfor
family. They shall be educated about the financial
donationandtransfusionofbloodandbloodproducts.
implications when there is a change in the patient
The staffshallbetrainedtoimplementthepoliciesand
condition or treatmentsetting.
procedures.Transfusionreactionsshallbeanalyzed for
5CAREOFPATIENTS preventiveandcorrectiveactions.
5.1 The care ofpatients shall be uniform indifferent 5.5.1 The healthcare facilities shall have programme
treatmentsettingsandshallbeguidedbytheapplicable toeducate the patientand the family regarding blood
laws.rules and regulations. donation.
3
IS15784:2007
5",Thereshallbedocumentedpolicies and procedures immunization and safe parenting and this shall be
toguidethecareofpatientsintheintensivecareandhigh documented in the medical record.
dependency units. The healthcare facilities shall have
5.10There shaIl be policies and procedures to guide
documented admission and discharge criteria for these
the care of patients undergoing moderate sedation.
units.Thestaffshallbetrained toapply thesecriteria.
Competentand trainedpersonsshallperformsedation.
5.6.1Adequatestaffand equipmentshall beavailable The person administering and monitoring sedation
inintensivecareand highdependency units.Aquality shall be different from the person performing the
assuranceprogrammeand infection control practices procedure/surgery.
shallbeimplemented.ThepoliciesshaIl have defined
5.10.1Intra-proceduremonitoringshaIl includeatleast
procedurestohandlesituationofbedshortageinthese
the heart rate: cardiac rhythm, respiratory rate,blood
units.
pressure. oxygen saturation, and level of sedation.
5.6.2Theunique needsofend ofterminaIlyillpatients Patientsshall bemonitoredaftersedation.Criteriashall
shall beidentifiedand cared for. bespecifiedand used beforetransferringoutthepatient
from the recovery area.
5.7Thereshall bedocumentedpoliciesand procedures
forthecareofvulnerablepatients(elderly, physically 5.10.2Equipmentand manpowershallbe availableto
and/ormentallychallengedand children).Theseshall rescue patients from a deeper level ofsedation than
be in accordance with the prevailing laws and the that intended.
national and internationalguidelines.
5.11 There shall be documented policies and
5.7.1 Care shall be organized and delivered in procedures to guide the administration ofanesthesia.
accordance with the policies and procedures. The All patientsfor anesthesiashall havea pre-anesthesia
healthcarefacilitiesshallprovideforasafeand secure assessmentbyaqualifiedindividual,whichshallresult
environment for this vulnerable group. StaffshaIl be in formulation ofdocumentedanesthesiaplan.
trained tocare for this vulnerablegroup.
5.11.t An immediate preoperative re-evaluationshall
5.7.2Adocumentedprocedureshall existforobtaining be carried out and documented.Theanesthesiologist
informed consent from the appropriate legal shall obtain informed consent for administration of
representative. anesthesia. During anesthesia, monitoring includes
regular and periodic recording ofheart rate, cardiac
5.8Thereshallbedocumentedpoliciesandprocedures
rhythm, respiratory rate, blood pressure, oxygen
for the care of high risk obstetrical patients. The
saturation, airway security and potency and level of
healthcare facilities shall define and display whether
anesthesia.
high risk obstetrical cases can be cared for or not.
Personscaring for high risk obstetrical casesshall be 5.11.2Each patient's post-anesthesia status shall be
trainedand competent. monitoredanddocumented.Aqualifiedindividualshall
apply defined criteriato transfer the patient from the
5.8.1 The healthcare facilities caring for high-risk
recovery area. AIl adverse anesthesia events shall be
obstetricalcasesshaIl have thefacilitiestotakecareof
recordedand monitored
neonatesofsuchcases. High-riskobstetricalpatient's
assessmentshall also includematernal nutrition. 5.12 There shall be documented policies and
procedures to guide the care of patients undergoing
5.9Thereshallbedocumentedpoliciesand procedures
surgical procedures.
for the care of pediatric patients. The healthcare
facilities shall define and display the scope of its 5.12.1 Surgical patients shall have a preoperative
pediatricservices. assessment and a provisional diagnosis documented
prior to surgery. The treating surgeon shall obtain
5.9.1Thepolicy forcareofneonatal patientsshaIl be
informed consent prior to the procedure.There shaIl
in consonance with the national/international
bedocumentedpolicyandproceduretopreventadverse
guidelinesand those who carefor children shall have
events like wrong site, wrong patient and wrong
agespecificcompetency.ThereshaIl beprovisionsfor
surgery.Personsqualified bylawshallbepermittedto
special care ofchildren including facility for breast
feeding. perform the surgical procedures.
5.12.2Abriefoperativenote shallbedocumentedprior
5.9.2Thepatientshallbeassessedfornutrition,growth,
psychosocialand immunizationstatus. to transfer out of patient from recovery area. The
operating surgeon shall also document the post
5.9.3Thereshall bepoliciesand procedurestoprevent operative plan of care. There shall be a quality
child/neonate abduction and abuse. The children's assuranceprogram followed for the surgicalservices,
family members shall be educated about nutrition: which includes surveillance ofthe operation theatre
4
IS15784:2007
environmentand monitoringofsurgicalsite infection unique needs ofsuch patient and family.These shall
rates. also include sensitively addressing issues such as
autopsyandorgandonation.Thestaffshallbeeducated
5.13 There shall be documented policies and
and trained inend-of-lifecare.
procedures for the care of patients under restraints
(physical and/orchemical).Reasonsforrestraintsshall
6 MANAGEMENTOFMEDICATION
be documented and such patients shall be more
frequently monitored.The staffshall receive training 6.1Thereshallbedocumentedpoliciesandprocedures
and periodic updating in control and restraint to guidethe healthcare facility ofpharmacy services
techniques. and usageofmedication.The policiesand procedures
shallcomplywiththeapplicable lawsandregulations.
5.14 There shall be documented policies and
A multidisciplinary committee shall guide the
proceduresforthemanagementofpain.Thehealthcare
formulation and implementationofthesepoliciesand
facilities shall respect and support the appropriate
procedures.
assessment and management ofpain for all patients.
The patient and family shall be educated on various 6.2There shall be a hospital formulary developed by
pain management techniques. the multidisciplinary committee. There shall be a
defined process for acquisition ofthese medications
5.15 There shall be documented policies and
and a process to obtain medications not listed in the
procedures for rehabilitative services during
formulary.
hospitalization andafterdischarge.Theseservicesshall
be commensurate with the healthcare facility's 6.3Thereshallbedocumentedpoliciesandprocedures
requirements and shall be provided by a forstorage ofmedication.Medicationsshallbestored
multidisciplinaryteam. inaclean,well-litand ventilatedenvironment.Sound
inventorycontrol practices shall guidestorageofthe
5.16 There shall be documented policies and
medicationsand shall be protectedfrom lossor theft.
procedures to guide all research activities in
compliancewithnationalandinternationalguidelines. 6.3.1 Sound alike and look alike medicationsshall be
storedseparatelyand thereshall beamethod toobtain
5.16.1 The healthcare facility shall have an ethics
medication when thepharmacy isclosed.Emergency
committee to oversee all research activities. The
medications shall be available all the time and
committee shall have the power to discontinue a
replenished inatimely mannerwhen used.
research trial when risks outweigh the potential
benefits. 6.4Thereshall bedocumentedpoliciesandprocedures
5.16.2 Patient's informed consent shall be obtained forprescriptionofmedications.Thehealthcarefacility
shalldeterminewhocanwriteorders.Theorders shall
before enteringthem inresearchprotocols.Theyshall
bewritteninauniformlocation inthemedicalrecords,
beinformedoftheirrighttowithdraw fromtheresearch
whichshallbeclear, legible,dated,named andsigned.
atany stageand also ofthe consequences (ifany) of
suchwithdrawal.Thepatientsshallbeassuredthattheir There shall be documented and implemented policy
refusal toparticipateorwithdrawalfrom participation, on verbal orders.
will not compromise their access to the healthcare 6.4.1Thehealthcarefacilitiesshalldefinealistofhigh
facility'sservices. risk medication, which shall be verified prior to
5.17 There shall be documented policies and dispensing.
procedures for nutritional therapy, assessment and
6.5Thereshallbedocumentedpoliciesandprocedures
reassessment. to guide the safe dispensing ofmedications. These
5.17.1 Patients shall receive food according to their policiesshallincludeaprocedureformedicationrecall.
clinical needs and shall have a written order for the 6.5.1Labellingrequirementsshall bedocumentedand
diet.Nutritionaltherapyshall beplannedandprovided
implemented by the healthcare facility. Expiry dates
in a collaborative manner preferably by a dietician.
shall bechecked priortodispensing.
When families provide food, they shall be educated
about the patient's diet limitations. Food shall be 6.6Thereshall bedefinedanddocumentedprocedures
prepared, handled, stored and distributed in a safe for medication administration and must be
manner. administeredbythose who are permittedbylawtodo
so.
5.18 There shall be documented policies and
procedurestoguidetheend-of-lifecare.Thesepolicies 6.6.1 Prepared medication shall be labelled prior to
and proceduresshall be inconsonance with the legal preparation of a second drug and Patient shall be
requirementsandshalladdresstheidentificationofthe identifiedpriortoadministration.Medication,dosage,
5
