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Medication Management News from JCAHO Executive Briefings

Accreditation Monthly, September 9, 2006

Medication reconciliation (NPSG 8a and 8b) and pharmacist review of orders prior to first dose (MM.4.10) were among the topics covered during this year's series of JCAHO Executive Briefings updates.  In both cases, the speaker indicated that clarifications or FAQs are expected to be written and released sometime in October to address several nagging questions plaguing the implementation of these requirements in hospitals nationwide.

The clarifications for the medication reconciliation topic will address in part the expectation to communicate the updated medication list to the next provider at time of discharge as well as whether reconciliation is required for outpatient imaging.

With regard to pharmacy review of the order prior to first dose, the clarification will address application of this standard in the emergency department setting and with the use of IV contrast in diagnostic imaging (the issue of pharmacy review prior to use of enteric contrast was clarified in the August issue of JCAHO Perspectives.)

MM.4.10 requires a pharmacist review of new physician orders prior to the first dose unless: 1) a physician controls the ordering, dispensing, and administration of the medication, or 2) when the resulting delay would harm the patient.

Although opinions within JCAHO vary as to what this first exception really means, even prior to the release of the aforementioned clarification, I think we are able to draw a clear line for the emergency department. If active medical screening has not begun or is underway (i.e., the emergency medicine physician has not reached a disposition decision), then the EM physician remains very involved in the care process. The "physician controlled environment" exemption (and possibly the "urgent need" exemption) is met and a pre-administration pharmacist's review is not required.

On the other hand, once the EM physician has reached a disposition decision (e.g., the patient will be admitted, we will observe the patient for 24 hours or less, we will wait until morning for a treadmill examination), it is no longer possible to argue "physician controlled environment." Therefore, unless there is an urgent need, the order must be reviewed by the pharmacy (when the pharmacy is open). 

I am hopeful the forthcoming clarification of MM.4.10 mirrors this logic and thus ensures not only a safe but also a practical medication ordering, dispensing, and administration process in the ED setting.

Speaking on behalf of my colleagues at The Greeley Company, any of us would be happy to assist you in fine-tuning your response to these changes and updates including helping to craft policies and effective processes designed specifically to fit your organization.  It may also be time to schedule an Unannounced Compliance Test-Run visit by one of our Greeley Company mock survey teams. 

For more information on these services, please call our Practice Manager, Sandi Reen at 888-749-3054, ext. 3263, e-mail sreen@greeley.com, or visit us on the Web at www.greeley.com. Our initial telephone consultation is completely free and without obligation.

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