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Tips for the new policy required under MM.2.20

Accreditation Connection, April 24, 2006

As reported in last week's Ask the Expert feature of Accreditation Connection, the JCAHO is adding an element of performance (EP) to its medication management standard MM.2.20 that takes effect July 1.

MM.2.20 requires the proper and safe storage of medications. The new EP requires a written policy addressing medication storage between when an individual healthcare provider receives the medication and when the drug is administered.

The policy should address safe storage, safe handling, security, and disposition of the drugs, including returning them to the pharmacy at the end of the individual's shift, according to Elizabeth DiGiacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant based in Trabuco Canyon, CA.

"The real issue is how you educate the staff on what the policy is," says DiGiacomo-Geffers.

After you train staff on the policy, conduct a posttest with a defined pass rate to see how well they understand the policy, she suggests.

"After the test, go out and see how they're complying with the policy," says DiGiacomo-Geffers.

The trouble spots that surveyors usually check include radiology, labor and delivery, perioperative, the intensive care unit, and physical therapy, during which topical steroids may be used to treat patients but not locked after use, she says.

Source: Adapted from an article that appeared in the April issue of Hospital Pharmacy Regulation Report.

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