Assuring Compliance with the JCAHO 2004 Standards: Medication Management

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Assuring Compliance withthe JCAHO 2004
Standards Medication Management

• Patricia C. Kienle, RPh, MPA, FASHP
• Medication Safety Manager
• Cardinal Health Pharmacy Management
• Patricia.Kienle_at_cardinal.com

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Medication Safety

• Federal and state laws and regulations
• Accrediting agencies
• Standards of practice

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JCAHO Focus 2004 Standards

• Patient safety
• Medication Management chapter
• Safety issues throughout other standards
• Provision of Care
• Process Improvement
• Leadership
• Information Management
• Human Resources

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Recurring themes

• Written policies and procedures
• Safety
• Security
• Education
• Staff knowledge and awareness
• Independent verification

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Medication Use System Phases

• Leadership and management
• Education
• Patient Information
• Selection
• Storage
• Ordering
• Dispensing
• Administering
• Monitoring

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Safety Patient information

• Minimal information
• Age and sex
• Current medications
• Relevant lab values
• Past sensitivities and allergies
• Available as appropriate
• Height and weight
• Pregnancy and lactation status
• Other information required by organization

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Safety Selecting Medications

• Risk evaluation for formulary
• medication errors
• abuse potential
• sentinel events
• Annual formulary review for safety and efficacy
• Organization identifies its high-risk medications

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Selecting Medications

• Resources are available prior to use of agent
• drug information
• laboratory test capability
• Review of non-formulary agents after 6 months
• Processes to address medication shortages and
  outages

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Safety Medication Storage

• No concentrated electrolytes on patient care
  areas
• Standard drug concentrations
• Medications easy to confuse are segregated
• look/sound alike
• reagents and chemicals

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Safety Ordering and Prescribing

• Identifies required elements of
• standing orders
• automatic stop orders
• range orders
• prn
• hold
• resume
• titrate

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Ordering and Prescribing Medications

• If and when brand and/or generic names will be
  used
• If and when indications for use are required
• Review and update preprinted order sheets
• Weight-based dosing for pediatrics when required
  by the package insert

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Ordering and Prescribing Medications

• Minimize verbal and telephone orders
• Read-back verbal and telephone orders to verify
• Action to take when medication orders are
  incomplete, illegible or unclear

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Safety Dispensing Medications

• Concerns clarified with prescriber prior to
  dispensing
• Labeled in standard manner
• Label minimum drug name, strength, amount
• Dispensed in ready-to-administer form
• Only pharmacy admixes sterile products

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Dispensing Unused recalled products

• Unused, expired and recalled medications are
  managed by pharmacy
• Recalls
• Medications retrieved
• Staff practitioners notified
• Patients notified if safety reasons involved

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Dispensing Non-24 hour pharmacy

• Pharmacist on call
• Access limited to approved set of medications
• Only trained, designated prescribers and nurses
  have access
• Another qualified healthcare professional reviews
  order and medication retrieved
• Pharmacist retroactive review
• Ongoing process improvement

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Safety Administering Medications

• Resolve significant concerns
• Education patient about potential ADRs

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Safety Monitoring Medications

• Monitor first few doses of medications
  administered
• Seeks patients perception of efficacy and side
  effects
• Identify trends and issues in internally-generated
  reports
• Method to evaluate medication management system
  for risk points and areas to improve safety
• Evaluate literature and new technologies

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Whats Next

• CAMH
• 2004 National Patient Safety Goals
• Best practices for patient safety

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