Darryl Rich, PharmD, MBA, FASHP, a surveyor for The Joint Commission, outlined seven of the top noncompliance issues in medication management in a recent webinar hosted by Pharmacy OneSource. The webinar, "TJC Hospital Pharmacy Update 2012," focused on common blunders and changes to medication management standards that healthcare leaders should be aware of.
1. Medication storage. Dr. Rich discussed several common reasons for noncompliance with The Joint Commission's medication storage standards. One of the top reasons for noncompliance was not labeling medications with contents, the expiration date and any applicable warnings. According to a 2011 survey by The Joint Commission, 10 percent of those surveyed violated this rule.
Another common mistake was allowing unlicensed personnel access to locked medications without authorizing them to do so in the hospital's policy or the staff member's job description. If the medications are locked in an OR and housekeeping and maintenance staff members need access to that area, their job description or the hospital's policy must authorize them to do so.
In addition, not placing carts in a secure area of the floor or locked room violates the medication storage standards. Carts should not be placed in corridors with public access, for instance. Carts, including crash carts and locked medication carts, need to be secured and located within observation of nurses, Dr. Rich said.
Not storing medications per the manufacturer's recommendations, when they exist, was another common violation. Package inserts and other manufacturer communications are acceptable, but literature and reference books that are in conflict with the manufacturer's recommendations are not, Dr. Rich said. Finally, failing to remove expired drugs, such as returned minibags with the drug vial attached, is a top reason for noncompliance in medication storage.
2. Medication orders. The number one issue with medication orders, at 16 percent noncompliance, was failure to clarify unclear, illegible and incomplete orders, according to Dr. Rich. As examples, he cited titration orders without the initial rate or clear parameters for titration labeled and range orders without labeled parameters for when to give a certain dose in the range.
3. Pharmacist review. A top noncompliance issue in this category was failure to receive pharmacist review when required. There are two new footnotes relating to this rule for 2012. One states that in the emergency room, a licensed independent practitioner does not need to remain at the bedside when the medication is administered but must be available to provide immediate intervention when needed. Secondly, pharmacist review of contrast orders is exempted in radiology, but hospitals are expected to define in protocol or policy the role of the LIP in direct supervision of the patient during and after the administration of an IV contrast media.
Failure of pharmacist review for therapeutic duplication was also an issue. For example, multiple narcotics for pain need to have clear guidelines for when they should be used, Dr. Rich said.
4. Medication preparation. One common violation of medication preparation standards was failure of all IV admixtures and compounded sterile medications to be prepared by the pharmacy. "[This issue] is going to be growing because surveyors were given education on this," Dr. Rich said.
In addition, medication preparation outside of the pharmacy needs to be in a functionally separate area that is clean, uncluttered and dedicated solely for IV preparation, according to Dr. Rich. "This is one a lot of surveyors were not aware of, but they have been informed so you will see more issues with [this requirement] in the future," Dr. Rich said.
5. Medication labeling. Top errors in this area were failure to label medications when not immediately administered and not labeling medications' expiration date when they were used in less than 24 hours. Dr. Rich shared a mnemonic device from a physician to remember medication labeling rules: "If it hits a table it needs a label."
6. High-alert medications. Violations of standards for high-alert medications included failure to follow policy for high-alert and hazardous medications and lacking a list of high-alert and hazardous medications.
7. Medication management system evaluation. Medication management system evaluation includes collecting data on the performance of the medication management system, analyzing the data to identify risk points and making improvements based on the data analysis using literature and best practices. Non-compliance in this area includes high-risk processes that are not according to best practices identified in the literature. For example, healthcare providers should not use the pull-back method to check IVs for high-alert medications in the pharmacy, which the Institute for Safe Medication Practices has identified as error-prone, Dr. Rich said.
In 2012, medication management system evaluation will include reconciling medication information, according to Dr. Rich. Providers will need to obtain and document information on medications a patient is taking when admitted to a hospital or seen in an outpatient setting. The hospital should also educate patients on the importance of keeping medication information current and informing providers of their medication list, Dr. Rich said.
Learn more about Pharmacy OneSource.
Learn more about The Joint Commission.
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1. Medication storage. Dr. Rich discussed several common reasons for noncompliance with The Joint Commission's medication storage standards. One of the top reasons for noncompliance was not labeling medications with contents, the expiration date and any applicable warnings. According to a 2011 survey by The Joint Commission, 10 percent of those surveyed violated this rule.
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Another common mistake was allowing unlicensed personnel access to locked medications without authorizing them to do so in the hospital's policy or the staff member's job description. If the medications are locked in an OR and housekeeping and maintenance staff members need access to that area, their job description or the hospital's policy must authorize them to do so.
In addition, not placing carts in a secure area of the floor or locked room violates the medication storage standards. Carts should not be placed in corridors with public access, for instance. Carts, including crash carts and locked medication carts, need to be secured and located within observation of nurses, Dr. Rich said.
Not storing medications per the manufacturer's recommendations, when they exist, was another common violation. Package inserts and other manufacturer communications are acceptable, but literature and reference books that are in conflict with the manufacturer's recommendations are not, Dr. Rich said. Finally, failing to remove expired drugs, such as returned minibags with the drug vial attached, is a top reason for noncompliance in medication storage.
2. Medication orders. The number one issue with medication orders, at 16 percent noncompliance, was failure to clarify unclear, illegible and incomplete orders, according to Dr. Rich. As examples, he cited titration orders without the initial rate or clear parameters for titration labeled and range orders without labeled parameters for when to give a certain dose in the range.
3. Pharmacist review. A top noncompliance issue in this category was failure to receive pharmacist review when required. There are two new footnotes relating to this rule for 2012. One states that in the emergency room, a licensed independent practitioner does not need to remain at the bedside when the medication is administered but must be available to provide immediate intervention when needed. Secondly, pharmacist review of contrast orders is exempted in radiology, but hospitals are expected to define in protocol or policy the role of the LIP in direct supervision of the patient during and after the administration of an IV contrast media.
Failure of pharmacist review for therapeutic duplication was also an issue. For example, multiple narcotics for pain need to have clear guidelines for when they should be used, Dr. Rich said.
4. Medication preparation. One common violation of medication preparation standards was failure of all IV admixtures and compounded sterile medications to be prepared by the pharmacy. "[This issue] is going to be growing because surveyors were given education on this," Dr. Rich said.
In addition, medication preparation outside of the pharmacy needs to be in a functionally separate area that is clean, uncluttered and dedicated solely for IV preparation, according to Dr. Rich. "This is one a lot of surveyors were not aware of, but they have been informed so you will see more issues with [this requirement] in the future," Dr. Rich said.
5. Medication labeling. Top errors in this area were failure to label medications when not immediately administered and not labeling medications' expiration date when they were used in less than 24 hours. Dr. Rich shared a mnemonic device from a physician to remember medication labeling rules: "If it hits a table it needs a label."
6. High-alert medications. Violations of standards for high-alert medications included failure to follow policy for high-alert and hazardous medications and lacking a list of high-alert and hazardous medications.
7. Medication management system evaluation. Medication management system evaluation includes collecting data on the performance of the medication management system, analyzing the data to identify risk points and making improvements based on the data analysis using literature and best practices. Non-compliance in this area includes high-risk processes that are not according to best practices identified in the literature. For example, healthcare providers should not use the pull-back method to check IVs for high-alert medications in the pharmacy, which the Institute for Safe Medication Practices has identified as error-prone, Dr. Rich said.
In 2012, medication management system evaluation will include reconciling medication information, according to Dr. Rich. Providers will need to obtain and document information on medications a patient is taking when admitted to a hospital or seen in an outpatient setting. The hospital should also educate patients on the importance of keeping medication information current and informing providers of their medication list, Dr. Rich said.
Learn more about Pharmacy OneSource.
Learn more about The Joint Commission.
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