Accreditation

Don't Overlook this New Medication Management Expectation

Accreditation Monthly, April 10, 2006

Included in the Spring 2006 "Update 1" to the JCAHO's Comprehensive Accreditation Manual for Hospitals are several changes to existing standards that will take effect July 1, 2006. (See pre-publication link to these changes at: www.jointcommission.org ) One change that I want to bring to your attention for your immediate action involves Medication Management standard MM.2.20.

Two new Elements of Performance (EPs) have been added to MM.2.20. EP 3 is an "A" EP calling for creation of 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 is a "C" or performance EP that requires implementation of this policy.

I was curious (as you might be) of exactly what problem JCAHO is trying to solve with the introduction of these two new elements. As you read them at face value the intent or purpose of each EP is not immediately obvious and thus hospitals run the risk of heading off in the wrong direction as they begin thinking about how to address these new EPs.

So I inquired with both the standards development and standards interpretation departments at JCAHO and confirmed my first guess - that the problem at the root of these new elements 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. It will be important to note that the practice of using "fanny packs" has been previously addressed in an FAQ, and found not to be an acceptable practice.

Element of Performance 3 requires a clearly written and sufficiently delineated policy to guide practitioner work flow or practice. For example, your policy might require nurses working in a medical/surgical unit with a centrally located ADM and medication room to do the following:

  1. Affix a single patient's Medication Administration Record (MAR) and education and teaching record to a clipboard.
  2. Log into the ADM and withdraw appropriate medication from the ADM one at a time and compare and confirm the drug, form (route), time, strength and dose against the MAR.
  3. Place the medication (one patient at a time) still in its original wrapper or container along with any necessary supplies on the clipboard and repeat.
  4. If interrupted or distracted while completing this process repeat confirmation of medication against MAR as described in step 2.
  5. Travel directly to the patient's room.
  6. Confirm two patient identifiers on the patient's name band against the same two identifiers on the MAR. (for patient's in isolation, placing the MAR in a sheet protector that can be wiped down upon exiting is acceptable practice)
  7. Administer each medication to the patient - again confirming drug, form, time, strength and dose - and immediately document on the MAR.
  8. Document any teaching and instruction provided the patient on the education and teaching record.
  9. Place any drug unable to be administered on the clipboard, document the reason(s) for non-administration on the MAR, return and credit the medication to the medication inventory.

Obviously these steps would need to be tailored to your organization to account for unique properties of your medication distribution system - for example, your particular MAR process, whether you have a centralized medication supply room or decentralized carts located in the corridor, the degree of computerization of this process, etc. Furthermore, in similar fashion you'll want to construct parallel but appropriately modified workflow steps similar to those noted above for respiratory therapy, anesthesia, and nurses working in care settings with characteristics that differ from the typical M/S unit (e.g., ICU, cardiac cath or GI labs, etc.)

The steps of this policy could either stand alone as a distinctive policy or you could incorporate them into an existing medication administration policy. Here is my compliance tip: It is important to construct the policy so it promotes safe care, is easy to learn, and is easy to perform 24/7 with minimal variation. If you make the process too complex, staff may find reason and opportunity to create shortcuts or workarounds and then you will run afoul with EP 4 which is a "C" EP designed to test staff performance and compliance as the policy is implemented. You may have a remarkable policy, but you've set yourself up for a Requirement for Improvement if staff fails to consistently comply with the policy.

Sincerely,

John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

For more information on our accreditation and regulatory compliance consulting services, click here or contact Sandi Reen, Practice Manager, at sreen@greeley.com or call 888/749-3054, ext. 3263.

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