Website spotlight: CMS 30-minute rule: How does this affect your facility?

Nurse Leader Insider, February 27, 2012

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In late 2011, CMS issued a memo to its state survey agency directors regarding updated guidance on medication administration. The intent, according to the memo, was to reflect current standards of practices related to timeliness of medication. Hospitals, the memo stated, are expected to establish policies and procedures for the timing of medication that provides a proper balance between patient safety and flexibility for work processes.

"Recognizing that it is no longer the standard of practice in the current hospital environment," CMS wrote in its memo, "we are removing reference to the so-called '30-minute rule' in the survey procedures portion of the guidance, which had established a uniform 30-minute window before or after the programmed time for all scheduled medication administration."

CMS now states that hospitals must adopt policies and procedures for medication administration based on standards of practice. This update allows hospitals more flexibility-they can now establish their own policies and procedures for timing of medication administration that address the nature of the medication involved, such as patient needs and specific clinical applications.

So what does this mean for hospitals and other affected healthcare facilities? Well, our mantra in this space is frequently "make sure policies match practice." In this case, the story is no different. Hospitals must verify that the policies and procedures approved by the medical staff are being followed-and if not, identify the reasons for noncompliance. Are they too restrictive, or too complex for staff and physicians?

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