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Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print.
The Medication Management (MM) Chapter provides the foundation for an effective and safe medication management system by addressing the following processes:
Selection and procurement
Storage
Ordering and transcribing
Preparing and dispensing
Administration
Monitoring
New for 2007
MM.4.10 Approved interim provisions for Element of Performance (EP) 1 relating to radiology practitioners became effective Jan. 1, 2007. Currently, EP 1 requires a pharmacist review of all prescriptions and medication orders prior to dispensing, unless a licensed independent practitioner (LIP) who can write orders (e.g., physicians, advanced practice nurses) controls the ordering, preparation and administration of the medication, or in urgent situations where a delay would harm the patient.
The interim provision released in January for the emergency department would have allowed medication orders to be carried out prior to a prospective pharmacist review, but required a retrospective medication review by a pharmacist within 48 hours. However, according to a report by the New Jersey Hospital Association in its NewsLink Today, April 11, 2007, The Joint Commission has suspended the ED interim provision and EP 1 stands as written. The interim provision for radiology practitioners continues.
According to The Joint Commission Perspectives January 2007:
Radiology modification to EP 1 - Allows the hospital's radiology services to develop protocols that define the role of the LIP in the direct supervision of a patient during and after IV contrast administration. The protocols must be approved by the medical staff and include the role of the LIP that allows for timely intervention in case of an emergency.
Avoiding Common Pitfalls
MM.2.20 MEDICATIONS ARE PROPERLY AND SAFELY STORED.
Forty percent of the hospitals surveyed in 2006 were not compliant with one or more EPs listed for this standard.
EP 3 & 4. Policies are in place that govern medication storage, handling and security from the time the medication reaches the unit to the time it is administered. Policies are implemented. The devil is in the implementation: Medication carts and medication room doors that are unlocked; medications left on top of the cart or on counters unattended; medications discontinued or medications for discharged patients that are not returned to the pharmacy; safe handling and storage of medications administered by respiratory therapists; open multi-dose vials that are not labeled with an expiration date, especially insulin; reconciling the count of controlled substances at the end of each shift; storage of IV solutions; and that "non-existent" stash that only the devil could have hidden when no one was looking are all problematic.
EP 3.20 MEDICATIONS ARE WRITTEN CLEARLY AND TRANSCRIBED ACCURATELY.
Twenty-six percent of the hospitals surveyed in 2006 were not compliant with one or more of the EPs listed for this standard.
Ten of the 11 EPs address policies that govern the communication (writing and transcription) of medication orders, remembering that unclear, incomplete, ambiguous communication is the No. 1 underlying cause of sentinel events. The 11th EP addresses implementation and, as previously mentioned, that is where problems occur.
This standard becomes a hot topic during the medication tracer, because this is when noncompliance is easily identified.
Legibility of the order: Can two healthcare professionals read the order?
Complete: Are all required elements present?
Indication: Do PRN orders have an indication for use included as part of the order?
Does the original order match the transcribed order in the medication administration record?
Can staff speak to:
unacceptable orders such as "resume previous medications"Â
when verbal orders are acceptable
automatic stop orders
orders for investigational drugs
drug protocols for heparin and insulin
MM.4.20 MEDICATIONS ARE PREPARED SAFELY.
EP 2 was new in July 2006 and requires a policy that addresses the safety and use of medications brought into the hospital by a practitioner from a source other than the hospital for use in patient care in the hospital. EP 3 speaks to its implementation. This is an uncommon occurrence but worth mentioning because it is "low volume, high risk," relatively new and can put the primary nurse in a quandary.
EP 4-6 address the safe and accurate preparation of medications. Things to think about:
Do nurses follow the same techniques in preparation as the pharmacist?
When and where do nurses, rather than pharmacists, prepare medications? Â
What education is offered to nurses related to preparation of medications and when did the nurse standing in the med room mixing that drip last attend?
MM.4.30 MEDICATIONS ARE LABELED.
The four EPs of this standard address a standardized method of labeling based on law, regulations or standards; identify that any time a medication or solution is prepared and not administered immediately it has to be labeled; and highlight labeling of individualized medications prepared for multiple specific patients and labeling medications prepared by one person and administered by another. Information that must be included on the label also is defined.
This standard applies to all areas of the hospital, from operating room surgeries to bedside procedures.
Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.
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