Medication Management Standards - Joint Commission

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Prepublication Requirements

• Issued December 18, 2013 •

The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals (as well as in the online E-dition®), accredited organizations and paid subscribers can also view them in the monthly periodical The Joint Commission Perspectives®. To begin your subscription, call 800-746-6578 or visit http://www.jcrinc.com.

Revisions to the Medication Management Standards Regarding Sample Medications APPLICABLE TO HOSPITALS Effective July 1, 2014

Medication Management Chapter MM.01.01.01 The hospital plans its medication management processes. Elements of Performance for MM.01.01.01 1.

The organization has a written policy that describes that the following information about the patient is accessible to licensed independent practitioners and staff who participate in the management of the patient’s medications: - Age - Sex - Diagnoses - Allergies - Sensitivities - Current medications - Height and weight (when necessary) - Pregnancy and lactation information (when necessary) - Laboratory results (when necessary) - Any additional information required by the organization (See also MM.04.01.01, EP 10; IM.02.01.01, EP 3; RC.01.01.01, EP 13) Note: This element of performance is also applicable to sample medications.

A

2.

The hospital implements its policy to make information about the patient accessible to licensed independent practitioners and staff who participate in the management of the patient’s medications. Note 1: This element of performance does not apply in emergency situations. Note 2: This element of performance is also applicable to sample medications.

A

Key: A indicates scoring category A; C indicates scoring category C; D indicates that documentation is required; M indicates Measure of Success is needed; indicates an Immediate Threat to Health or Safety; indicates situational decision rules apply; indicates direct impact requirements apply;

indicates an identified risk area

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013

MM.01.01.03 The hospital safely manages high-alert and hazardous medications. Elements of Performance for MM.01.01.03 1.

The hospital identifies, in writing, its high-alert and hazardous medications. * (See also EC.02.02.01, EP 8) Note: This element of performance is also applicable to sample medications. Footnote *: For a list of high-alert medications, see http://www.ismp.org. For a list of hazardous medications, see http://www.cdc.gov/niosh/docs/2012-150/.

A

2.

The hospital has a process for managing high-alert and hazardous medications. (See also EC.02.02.01, EP 8; MM.03.01.01, EP 9) Note: This element of performance is also applicable to sample medications.

A

3.

The hospital implements its process for managing high-alert and hazardous medications. (See also EC.02.02.01, EPs 1 and 8) Note: This element of performance is also applicable to sample medications.

C

5.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital reports abuses and losses of controlled substances, in accordance with law and regulation, to the individual responsible for the pharmacy department or service and, as appropriate, to the chief executive. Note: This element of performance is also applicable to sample medications.

A

MM.01.02.01 The hospital addresses the safe use of look-alike/sound-alike medications. Elements of Performance for MM.01.02.01 1.

The hospital develops a list of look-alike/sound-alike medications it stores, dispenses, or administers. Note 1: One source of look-alike/sound-alike medications is The Institute for Safe Medication Practices (http://www.ismp.org/Tools/confuseddrugnames.pdf). Note 2: This element of performance is also applicable to sample medications.

A

2.

The hospital takes action to prevent errors involving the interchange of the medications on its list of look-alike/sound-alike medications. Note: This element of performance is also applicable to sample medications.

A

3.

The hospital annually reviews and, as necessary, revises its list of lookalike/sound-alike medications. Note: This element of performance is also applicable to sample medications.

A

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013

MM.02.01.01 The hospital selects and procures medications. Elements of Performance for MM.02.01.01 1.

Members of the medical staff, licensed independent practitioners, pharmacists, and staff involved in ordering, dispensing, administering, and/or monitoring the effects of medications develop written criteria for determining which medications are available for dispensing or administering to patients. Note: This element of performance is also applicable to sample medications.

A

2.

The hospital develops and approves criteria for selecting medications, which, at a minimum, include the following: - Indications for use - Effectiveness - Drug interactions - Potential for errors and abuse - Adverse drug events - Sentinel event advisories - Population(s) served (for example, pediatrics, geriatrics) - Other risks - Costs Note: This element of performance is also applicable to sample medications.

A

3.

Before using a medication new to the hospital, the hospital determines a method to monitor the response of the patient. Note: This element of performance is also applicable to sample medications.

A

7.

The hospital has a process to select, approve, and procure medications that are not on its formulary. Note: This element of performance is also applicable to sample medications.

A

8.

The hospital implements the process to select, approve, and procure medications that are not on its formulary. Note: This element of performance is also applicable to sample medications.

C

MM.03.01.01 The hospital safely stores medications. Elements of Performance for MM.03.01.01 2.

The hospital stores medications according to the manufacturers' recommendations or, in the absence of such recommendations, according to a pharmacist's instructions. Note: This element of performance is also applicable to sample medications.

C

3.

The hospital stores all medications and biologicals, including controlled (scheduled) medications, in a secured area to prevent diversion, and locked when necessary, in accordance with law and regulation. Note 1: Scheduled medications include those listed in Schedules II–V of the Comprehensive Drug Abuse Prevention and Control Act of 1970. Note 2: This element of performance is also applicable to sample medications.

A

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013 4.

The hospital has a written policy addressing the control of medication between receipt by an individual health care provider and administration of the medication, including safe storage, handling, security, disposition, and return to storage. Note: This element of performance is also applicable to sample medications.

A

5.

The hospital implements its policy addressing the control of medication between receipt by an individual health care provider and its administration. Note: This element of performance is also applicable to sample medications.

C

6.

The hospital prevents unauthorized individuals from obtaining medications in accordance with its policy and law and regulation. Note: This element of performance is also applicable to sample medications.

A

7.

All stored medications and the components used in their preparation are labeled with the contents, expiration date, and any applicable warnings. Note: This element of performance is also applicable to sample medications.

C

8.

The hospital removes all expired, damaged, and/or contaminated medications and stores them separately from medications available for administration. Note: This element of performance is also applicable to sample medications.

C

10.

Medications in patient care areas are available in the most ready-to-administer forms commercially available or, if feasible, in unit doses that have been repackaged by the pharmacy or a licensed repackager. Note: This element of performance is also applicable to sample medications.

C

18.

The hospital periodically inspects all medication storage areas. Note: This element of performance is also applicable to sample medications.

C

19.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a pharmacy directed by a registered pharmacist or a supervised drug storage area, in accordance with law and regulation. Note: This element of performance is also applicable to sample medications.

A

MM.03.01.05 The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners. Elements of Performance for MM.03.01.05 1.

The hospital defines when medications brought into the hospital by patients, their families, or licensed independent practitioners can be administered. Note: This element of performance is also applicable to sample medications.

A

2.

Before use or administration of a medication brought into the hospital by a patient, his or her family, or a licensed independent practitioner, the hospital identifies the medication and visually evaluates the medication's integrity. (See also MM.05.01.07, EP 3; MM.06.01.01, EP 4) Note: This element of performance is also applicable to sample medications.

C

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013 3.

The hospital informs the prescriber and patient if the medications brought into the hospital by patients, their families, or licensed independent practitioners are not permitted. Note: This element of performance is also applicable to sample medications.

C

MM.04.01.01 Medication orders are clear and accurate. Elements of Performance for MM.04.01.01 10.

The hospital defines, in writing, the circumstances for which weight-based dosing is required for pediatric populations. (See also MM.01.01.01, EP 1) Note: This element of performance is also applicable to sample medications.

A

MM.05.01.09 Medications are labeled. Elements of Performance for MM.05.01.09

1.

Medication containers are labeled whenever medications are prepared but not immediately administered. Note 1: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process. Note 2: This element of performance is also applicable to sample medications.

A

2.

Information on medication labels is displayed in a standardized format, in accordance with law and regulation and standards of practice. Note: This element of performance is also applicable to sample medications.

A

3.

All medications prepared in the hospital are correctly labeled with the following: Medication name, strength, and amount (if not apparent from the container). Note: This element of performance is also applicable to sample medications.

A

MM.05.01.11 The hospital safely dispenses medications. Elements of Performance for MM.05.01.11 1.

The hospital dispenses quantities of medications that are consistent with patient needs. Note: This element of performance is also applicable to sample medications.

C

2.

The hospital dispenses medications and maintains records in accordance with law and regulation, licensure, and professional standards of practice. Note 1: Dispensing practices and recordkeeping include antidiversion strategies. Note 2: This element of performance is also applicable to sample medications.

C

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013

MM.05.01.17 The hospital follows a process to retrieve recalled or discontinued medications. Elements of Performance for MM.05.01.17 1.

The hospital has a written policy describing how it will retrieve and handle medications within the hospital that are recalled or discontinued for safety reasons by the manufacturer or the US Food and Drug Administration (FDA). (See also EC.02.01.01, EP 11) Note: This element of performance is also applicable to sample medications.

A

2.

The hospital implements its policy on retrieving and handling medications when they are recalled or discontinued for safety reasons. (See also EC.02.01.01, EP 11) Note: This element of performance is also applicable to sample medications.

A

3.

When a medication is recalled or discontinued for safety reasons by the manufacturer or the US Food and Drug Administration (FDA), the hospital notifies the prescribers and those who dispense or administer the medication. (See also EC.02.01.01, EP 11) Note: This element of performance is also applicable to sample medications.

C

4.

When required by law and regulation or hospital policy, the hospital informs patients that their medication has been recalled or discontinued for safety reasons by the manufacturer or the US Food and Drug Administration (FDA). (See also EC.02.01.01, EP 11) Note: This element of performance is also applicable to sample medications.

C

MM.05.01.19 The hospital safely manages returned medications. Elements of Performance for MM.05.01.19 1.

The hospital determines under what circumstances unused, expired, or returned medications will be managed by the pharmacy or the hospital. Note: This element of performance is also applicable to sample medications.

A

2.

When the hospital accepts unused, expired, or returned medications, it has a process for returning medications to the pharmacy’s control that includes procedures for preventing diversion. Note: This element of performance is also applicable to sample medications.

A

3.

The hospital determines if and when outside sources are used for destruction of medications. Note: This element of performance is also applicable to sample medications.

A

4.

The hospital implements its process for managing unused, expired, or returned medications. Note: This element of performance is also applicable to sample medications.

C

Copyright 2013 The Joint Commission

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Prepublication Requirements continued December 17, 2013

MM.07.01.03 The hospital responds to actual or potential adverse drug events, significant adverse drug reactions, and medication errors. Elements of Performance for MM.07.01.03 1.

The hospital has a written process to respond to actual or potential adverse drug events, significant adverse drug reactions, and medication errors. Note: This element of performance is also applicable to sample medications.

A

2.

The hospital has a written process addressing prescriber notification in the event of an adverse drug event, significant adverse drug reaction, or medication error. Note: This element of performance is also applicable to sample medications.

A

3.

The hospital complies with internal and external reporting requirements for actual or potential adverse drug events, significant adverse drug reactions, and medication errors. Note: This element of performance is also applicable to sample medications.

C

5.

The hospital implements its process for responding to adverse drug events, significant adverse drug reactions, and medication errors. Note: This element of performance is also applicable to sample medications.

C

MM.08.01.01 The hospital evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information) Elements of Performance for MM.08.01.01 1.

The hospital collects data on the performance of its medication management system. (See also PI.01.01.01, EPs 14 and 15) Note: This element of performance is also applicable to sample medications.

A

2.

The hospital analyzes data on its medication management system. Note: This element of performance is also applicable to sample medications.

A

3.

The hospital compares data over time to identify risk points, levels of performance, patterns, trends, and variations of its medication management system. Note: This element of performance is also applicable to sample medications.

A

6.

The hospital takes action on improvement opportunities identified as priorities for its medication management system. (Refer to PI.03.01.01, EP 2) Note: This element of performance is also applicable to sample medications.

A

Copyright 2013 The Joint Commission

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Medication Management Standards - Joint Commission

Prepublication Requirements • Issued December 18, 2013 • The Joint Commission has approved the following revisions for prepublication. While revised...

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