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Medication security was a recent JCAHO survey focus

Accreditation Connection, April 19, 2004

One east Texas hospital changed how it monitors narcotics after its JCAHO survey in January.

JCAHO surveyors scrutinized how Henderson (TX) Memorial Hospital reviews narcotic records in the intensive-care unit (ICU) and skilled nursing facility (SNF), says pharmacy director Ted Raines, RPh. Surveyors also wanted to know how often staff checked narcotic discrepancy reports for drug waste or theft and how the pharmacy reviewed after-hours medication orders.

Surveyors traced patient care by using select medical records and visiting the units that cared for the patients. For example, surveyors followed one patient backward through her entire stay, from her SNF treatment back through the medical-surgery ward to the operating room (OR) to the emergency room and her ambulance ride.

From these patient tracers, surveyors asked staff questions about issues that may arise during a patient's stay, including

• 
  medication security
• 
  medication distribution
• 
  after-hours medication access

"Medication security was their big thing," Raines says. "It was an intense three days."

Check your narcotic records

Henderson Memorial Hospital's ICU and SNF are the only two units that do not have Pyxis automated medication-storage cabinets, Raines says. Nurses sign out narcotics using inventory sheets, and nursing staff review them at the end of every shift to make sure the drugs listed on the sheet match the drugs taken from the unit's stock.

Surveyors wanted to know how often Raines personally inspected the narcotics records. "They expect me to go down there periodically to do the counts," Raines says. "I said, 'I can't be there all the time. I trust the nurse.' [The surveyor] said, 'I don't think that would hold up in court.' "

Tip: Check narcotic records monthly if your hospital does not use an automated dispensing system for narcotics.

As a result of the survey, Raines will now check the narcotics records once a month on the ICU and SNF units. Henderson Memorial Hospital will install Pyxis systems in those two units in the coming months, which will eliminate the need for paper-based narcotics records.

The hospital planned to install Pyxis on those two units before its survey, but the process hadn't been complete by the time the surveyors arrived, Raines says.

Check frequently for discrepancies

JCAHO surveyors also scrutinized how the pharmacy checked narcotic-discrepancy reports. The reports help the pharmacy determine whether drugs are missing, stolen, or wasted, Raines says.

Surveyors recommended that Raines and his staff run weekly reports on the hospital's Pyxis system to check discrepancies in the stock's narcotic inventory. These reports outline which nurse checked out the narcotic and when the nurse took it from the Pyxis cabinet.

Pharmacy staff will be able to see whether there is a large amount of narcotic waste and look for trends to see whether someone is stealing narcotics.

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