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Leaving sample drugs help safeguard facilities without a 24-hour pharmacy

Nurse Leader Weekly, August 1, 2003

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) medication management standard MM.4.5 requires organizations to develop specific processes and procedures to safely provide medications to patients when the pharmacy is closed. How does your facility comply?

Administrators at St. John's Medical Center in Jackson, WY, created several measures to protect patients from potential medication errors after hours, says Linda Donohue, RN, the facility's JCAHO coordinator, performance improvement director, and quality resource member.

Her facility uses Pyxis machines, which contain about 90% of the medications the facility dispenses. If a patient needs a medication from the 10% of drugs not available via Pyxis, the night shift supervisor has keys to the pharmacy and can enter after hours to obtain the medication.

To cover the gap between when pharmacy staff leave for the day and the night shift supervisor comes on duty, several charge nurses also hold keys to the pharmacy, adds Donohue.

All nurses with access to the pharmacy after hours must pass an annual competency exam and undergo orientation to the pharmacy. The hospital maintains a list of all approved nurses.

Nurses leave a sample drug at night When nurses enter the pharmacy at St. John's, they must now follow a new policy that administrators created earlier this year.

"They have to leave a copy of the doctor's orders, and they have to leave a sample of the drug that they took [in the pharmacy]," says Donohue. "It's worked out very well."

Nurses take two portions of the medication from the shelf-one to give to the patient and the other to leave on the counter with the orders. That way, when the pharmacist comes in the following day, he or she can verify that the nurse took the correct medication for that patient.

Monthly reviews decrease pharmacy entries

St. John's nurses who enter the pharmacy after hours must also sign a log each time they enter and write down the medication they take. The facility's pharmacists review the log each month, says Donohue.

If pharmacy notes a frequency in a certain medication, they then add it to the Pyxis machine to reduce entries into the pharmacy.

Adapted from: Hospital Pharmacy Regulation Report, www.hcmarketplace.com/Prod.cfm?id=1505&S=ENMW.

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