Medication Management Policy and Procedure Redevelopment for Dublin Dental University Hospital

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“HCI impressed us with their ability to expertly map out our processes for medication management. With their in-depth regulatory knowledge and expertise, we were able to develop a comprehensive medication management policy and procedure which is in line with regulatory requirements and best practice techniques.”

David Barry

CEO, Dublin Dental University Hospital


Dublin Dental University Hospital (DDUH), established in 1899, is a centre of excellence in the delivery of dental care to patients. They are a major dental teaching hospital, training postgraduate and undergraduate dental students, student dental nurses, dental technicians and dental hygienists.  The current Draft Medication Management Policy required review to make it site specific to DDUH and to ensure it was up to date and in line with best practice and regulatory requirements. Consequently, DDUH commissioned HCI to undertake a review of the medication management processes at DDUH and to develop an updated Medication Management Policy in line with regulatory requirements and best practice.


  • Process map current medication management processes with senior management in DDUH.
  • Determine all aspects of medication management.
  • Update the current Medication Management Policy document in line with national regulatory requirements and best practice.


In order to ensure the DDUH implemented a best practice Medication Management Policy and Procedure, HCI provided the following solution:

Development of project plan.

Document review of all relevant documents pertaining to Medication Management at DDUH.

Process mapping held remotely via MS Teams with key stakeholders from DDUH.

Senior Management review and provide feedback on process flows.

Development of Medication Management Policy and Procedure.

Client review of Draft Medication Management Policy and Procedure and feedback is provided to HCI.

Feedback is incorporated and Medication Management Policy and Procedure is approved.


Process mapping was held remotely which was a new format for some stakeholders. However, HCI guided and supported them through the process which in turn worked well, made better use of resources and was in line with COVID-19 guidelines.


Following the document review and process mapping, HCI developed a comprehensive Medication Management Policy and Procedure for DDUH that is in line with regulatory requirements and best practice including but not limited to, the Dental Council, HIQA and Joint Commission International (JCI). This document sets out a framework for the ordering, prescribing, dispensing, supply, handling, storage, administration, and disposal of all medication, including controlled medications, within DDUH.  In addition, HCI provided DDUH with a set of Quality Improvement Plans (QIPs) to address any gaps that were identified during the process mapping phase.


  • Comprehensive and independent review of medication management processes, that sought opinions from all key people.
  • Risk areas and gaps were identified during process mapping and QIPs were provided to address these.
  • Roles and responsibilities are clearly defined for staff in relation to medication management.
  • The JCI Accreditation Standards for Hospitals, 7th Edition were utilised as the basis for the evidence-based processes within the new Medication Management Policy. This is seen as the gold standard.
  • HIQA’s Guide to the inspection of services providing medical exposure to ionising radiation was considered as part of the process mapping phase as HIQA are due to inspect Dental Services with respect to this guidance.
  • Implementing a best practice Medication management policy and procedure helps to reduce the possibility of medication errors.
  • The Medication Management Policy and Procedures ensures there is appropriate clinical governance and oversight of medication management practices.


Serena Horkan

Senior Quality and Safety Specialist

Phone: +353 (0)1 629 2559


To learn more about how we can help, get in touch today.