Joint Commission Rescinds January 2007 Interim Action Requiring Retrospective Pharmacist Review of Orders Prior to First Dose in the Emergency Department

Accreditation Monthly, July 19, 2007

In a bulletin emailed recently to all accredited hospitals and republished in the July 2007 issue of Joint Commission Perspectives, Joint Commission announced that effective immediately both of the two exceptions footnoted to standard MM.4.10 EP 1 may be applied more generally in the emergency department setting.

This change in course will at least temporarily free hospitals from the requirement to have a pharmacist either prospectively or retrospectively review all medication orders in the emergency department prior to first dose. Many found this requirement to be costly, difficult (if not impossible) to staff, and often the direct cause of delays in providing necessary treatment and increased waiting times in the ED.

Element of Performance 1 (EP1) for this standard retains it's originally text. It requires that "prior to dispensing or retrieval from floor stock or an ADM, a pharmacist (must) review all prescription or medication orders unless (exception #1) a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or (exception #2) in urgent situations when the resulting delay would harm the [patient], including situations in which the [patient] experiences a sudden change in clinical status."

The trouble with these two exceptions as originally written is they did not provide relief for the vast majority of patients or medication orders written in the emergency department because the rules further specified that to qualify for exception #1 the ED physician had to be literally at the bedside of the patient as the drug was being administered and "urgent situation" was interpreted as "code blue" or trauma circumstances.

Now exception #1 may be interpreted to be in effect if the physician (licensed independent practitioner) "remains available to provide immediate intervention should a patient experience an adverse medication event." So, the physician no longer needs to be physically at the bedside, but rather, simply in the department.

Furthermore, it is now up to the physician who is providing care to the patient to determine or define if the situation is an urgent situation and thus covered by exception #2. In other words, if the order is written and understood to be written as a "now" order, the medication may be given "now" prior to prospective review by pharmacy.

The Joint Commission (TJC) cautions that this standard remains under revision and new requirements are presently in field review and testing. A task force of stakeholders convened by TJC including the American Society of Health-System Pharmacists (ASHP), the American College of Emergency Physicians (ACEP) and Emergency Nurses Association (ENA) are hard at work hammering out new language.

If your hospital has successfully installed and sustained a system by which medication orders in the ED are prospectively reviewed by pharmacy, The Joint Commission encourages you to continue on this path and The Greeley Company certainly concurs with this advice. But stay tuned. Later this fall the revisions to MM.4.10 EP 1 will be announced with a (likely) January 1, 2008 effective date. My hunch is the new requirement will require hospitals to carve out a subset of high-risk medications that will by definition require a pharmacist to either prospectively or retrospectively review prior to first dose, leaving the majority of other low-risk medications to continue to fall under the "physician controlled environment" exception #1 or urgent situation exception #2.

Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to assist you in fine-tuning your response to these changes including helping to craft policies and effective processes designed specifically to fit your organization. It may also be time to schedule an Unannounced Survey Vulnerability Assessment. For more information please call Stacey Koch, Director of Client Relations, at 888-749-3054, ext. 3193.

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