Here's how JCAHO defines compliance

Since there are no guarantees as to when — or if — the objections of emergency medicine groups to standard MM 4.10 from the Joint Commission on Accreditation of Healthcare Organizations will result in any modifications, it's critical for ED managers to know exactly what the Joint Commission is looking for when it comes to compliance with the standard.

Mary McNeily, associate director of standards interpretation, offers the following clarification: "MM 4.10 . . . requires that before dispensing, removal from floor stock, or removal from an automated storage and distribution device, a pharmacist reviews all prescription or medication orders unless an LIP [licensed independent practitioner] controls the ordering, preparation, and administration of the medication, or in urgent situations, when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status (for example, new onset of nausea). The standards regarding pharmacist review of medication orders . . . apply whether the patient is located in the emergency department, PACU [post-anesthesia care unit], or elsewhere."

There are two exceptions, she notes, which are not based on the location of the patient: circumstances in which the LIP maintains control of the medication or when the circumstances are urgent or emergent, and harm would come to the patient by waiting for a pharmacist to review the medication.

The purpose of the exception when physicians control the dispensing and administration is to allow physicians to accept full responsibility for the dispensing, preparation, and administration of medications under circumstances in which delay could harm the patient, McNeily explains. Physician control means that a physician (or other licensed independent practitioner) performs the function directly or is physically present at the bedside to direct the activity.

The precise definition of LIP control has been a subject of much discussion, McNeily notes, and the current interpretation is that "the LIP must remain with the patient, at the bedside, during the administration of the medication."

However, she says, many organizations have exempted areas such as EDs, PACUs, intensive care units (ICUs), neonatal ICUs, and labor and delivery departments from the requirements of MM.4.10 for pharmacist review, based on the LIP being present in the ED or other area. "This practice is not in compliance with the standards," McNeily says. The LIP must actually be performing the function or at the bedside to direct if for the LIP exemption to be applicable."

Tom Scaletta, MD, FAAEM, president of the American Academy of Emergency Medicine, asserts that the Joint Commission has left a small "escape hatch" in its standards. "They said that time-sensitive meds are not covered," he says. "You could expand your interpretation and say that all meds in the ED — even a tetanus shot — are time-sensitive. It really depends on how aggressive you want to be with that interpretation."

McNeily disagrees. "Many organizations have classified entire units as exempt from pharmacist review based on urgency," she says. "This practice is not in compliance with the standards." The exemption for urgency, she explains, must be applied to each individual circumstance in which the classification of urgency is based on a judgment that waiting for pharmacist review would result in harm to the patient.


For more information on compliance with National Patient Safety Goal No. 8 and the medication reconciliation standard (MM 4.10), contact:

  • Mary McNeily, Associate Director of Standards Interpretation, Standards Interpretation Group, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5900.