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Four simple steps to monitor goals compliance in the pharmacy

Pharmacy Regulation Resource, September 22, 2004

Take the lead for monitoring compliance with the National Patient Safety Goals within the pharmacy, but make sure you collaborate with other disciplines to coordinate information and data.

Below are four steps to monitor compliance with the National Patient Safety Goals. Following them will help ensure your hospital meets JCAHO requirements.

1. Identify a point person. One individual, such as a quality manager, should be responsible for overall compliance within the organization. That person can then delegate auditing responsibilities to the appropriate departments.

For example, a pharmacy director or pharmacy staff member could be the point person to monitor compliance with the medication-related goals-improve the safety of medications and reconcile all medications across the continuum of care.

2. Work together. The point person responsible for monitoring compliance can also involve nursing staff and others in the auditing process to get their input. The point person can then report back to the quality manager and the board of trustees.

3. Establish an info stream. Conduct a chart audit to check compliance with reconciling medications across the continuum of care. Check to see if the chart includes a complete medication list. Ensure that any medications left off the list were discontinued and not omitted by mistake.

You can then enter data in a spreadsheet or database to calculate a compliance percentage.

4. Take action. Once you conduct your audits, you may make changes based upon the data collected. For example, you may need to change the organization of medications on the pharmacy shelves if you notice staff have confused look-alike and sound-alike medications.

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