Accreditation

How to handle malignant hyperthermia

Briefings on Accreditation and Quality, October 1, 2017

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Schedule staff drills and update emergency carts to prevent RFIs

Malignant hyperthermia (MH) is a key focus for surveyors. Schedule drills for staff on finding the emergency carts with the proper drugs to treat MH, ensure the drugs in those carts are kept up to date, and document education and training in their use.

Failures to properly prepare to respond to the rare but potentially fatal condition associated with some anesthesia could result in Requirements for Improvement (RFI) cited under The Joint Commission’s Medication Management standard MM.03.01.03, which outlines requirements for handling emergency medications.

Hospital accreditation managers have also reported being cited under HR.01.04.01, requiring hospitals to provide proper orientation to staff.

Concerns begin with CMS

CMS has had long-standing concerns about a hospital staff’s ability to quickly respond to MH, warns Kurt Patton, MS, RPh, a former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting in Naperville, Illinois.

“This issue has been around forever,” notes Patton. “The Joint Commission has picked up on it more recently.”

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