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New element of performance for MM.2.20 requires a policy

Accreditation Connection, April 17, 2006

Two new elements of performance (EPs) have been added to MM.2.20, says John Rosing, practice director of accreditation and regulatory compliance with The Greeley Company, a division of HCPro Inc. They are effective July 1, 2006.

EP 3 calls for a policy covering the storage and handling of medication from the time a nurse or other authorized clinician first lays hands on the medication to the time the medication is administered. The policy must address at a minimum the storage, handling, security, and disposition (at end of shift) of medications during this time period. EP 4 requires implementation of this policy.

The root of these new EPs has everything to do with the manner and variation in which, for example, nurses or other authorized individuals remove medication from an Automated Dispensing Machine (ADM) or central medication supply room and then carry them in one way or another down the corridor to administer to their assigned patients. Administration in the PACU would be a likely target of review by JCAHO. Another target is the manner or variation in which respiratory therapist carry medication from the supply source of the medication to the patient. The practice of obtaining medications for more than one patient will be subject to review by this EP.

Yet another example is the manner or variation in which anesthesia providers handle their medications during a routine day moving between the operating rooms and PACU, again, from supply source to the individual patient.

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