Organizations join forces against Joint Commission medication rules

Overburdened EDs differ from other hospital departments, they argue

On May 30, 2006, the American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and the Emergency Nurses Association (ENA) did something they had never done before: They wrote a letter in concert to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) expressing their concerns about an issue affecting emergency medicine practitioners. The issue was the Joint Commission's new standard (MM 4.10), which requires pharmacist review of orders prior to administration, and National Patient Safety Goal (NPSG) No. 8: "Accurately and completely reconcile medications across the continuum of care." Both went into effect in January 2006.

"It is my understanding that the Joint Commission wants every medication given to patients in the ED to be reviewed by a pharmacist unless the urgency of giving is such [that it is not practical]," says Richard Bukata, MD, medical director of The Center for Medical Education in Creamery, PA. In terms of NPSG No. 8, a staff member, such as a nurse, is required to write down every medication the patient is taking, he says.

"They want the ED to do this on everyone who may get a drug," says Bukata. "We would be disproportionately burdened." In addition, he says, medication administration in the ED should not require first-dose review by a pharmacist "since ED physicians are licensed independent practitioners, so we are already meeting the standard."

Tom Scaletta, MD, FAAEM, president of AAEM, says, "We are not trying to play a game. We think this is a losing hand." He says the ED is a unique environment, in that you have the patients, the doctors, and the nurses all together during the duration of treatment.

"It's not like a medical ward where the doc walks in and out, and the nurse is not sure what he wrote or said," Scaletta continues. "You have two professionals there with the patient and family, who generally know what the patient is allergic to, what they can tolerate, and so forth."

Denise King, RN, MS, CEN, 2006 secretary/ treasurer of the ENA and point person on the joint ACEP/AAEM/ENA task force for medication standards, agrees. "The Joint Commission had very little data documenting that there was indeed a problem with ED physicians ordering wrong doses and so forth," she says. "In fact, there is no data to support that this drastic action is needed."

Bukata says, "I've reviewed the literature and basically concluded using data from the [U.S. Pharmacopeia and National Formulary] that one in 10,000 ED patients may be harmed by a meds-related misadventure."

But such statistics can be deceiving, responds Robert Wise, MD, the Joint Commission's vice president, Division of Standards and Survey Methods. "It's very difficult to figure out how many problems of medication administration occur, because once you give the meds the patients often leave," he says. "Many pharmacists would disagree with their assertions."

However, he adds, Scaletta brings up important points that in certain situations, if there were not other exceptions, providers could inadvertently make things worse. "In the ED, [the potential safety benefits] need to be clearly worth the increased problem of access this may involve," Wise says.

Standards not practical

While sharing the Joint Commission's concerns for patient safety, the three organizations say the new standards do not reflect the reality of life in the ED.

Scaletta says, "No system is perfect, but adding a third professional also slows things down. The recommendation means the doctor would write the order, the nurse would go to the pharmacy, get it approved, and then unlock the Pyxis drawer to get the drug and give it to the patient."

These additional steps are unnecessary, he asserts, because the ED "uses a pretty finite group" of medications with which the staff is very familiar. "When we do use something unusual, it's often because we discussed it with a specialist — and we may actually get it from the pharmacy because it's not in our Pyxis — so the pharmacy is involved," Scaletta notes. "And if it's something super-dangerous, like tPA [tissue plasminogen activator], protocols are in place, so we have taken precautions we think are adequate."

King says, "When you consider the meds we routinely administer, there are so many that have low risk. Having a pharmacist review the order every time you give Tylenol is ridiculous." In addition, she notes, many hospitals do not have 24/7 pharmacy coverage. "Where do you get the [review] people?" she poses.

In terms of medication reconciliation, King says the task force asked the Joint Commission for clarification. The comment that came back was that it is their expectation that every patient who presents would have full reconciliation of all meds, and if the patient couldn't provide the information, the ED should contact the patient's pharmacy or family physician to complete it, she reports. "When you consider the volume of patients who come in to the ED, I question the benefit it would provide," King says.

In addition, she says, during the assessment the patient is routinely asked if they are allergic to any drugs. "We do make an effort to determine such issues, and these are documented on the ED record," says King. "We really feel this does not help achieve our ultimate goal of efficient, safe, quality patient care in the ED."

Bukata thinks the Joint Commission has gone overboard. "This patient safety business is consuming everyone," he asserts. "I think it's an important issue, but personally it does not in any way rival the importance of providing patients with solid, evidence-based medicine."

Wise disagrees. "It may be accurate that they give only one or two doses of meds in the ED, and they usually have few side effects, but the patient is coming to the ED for all kinds reasons that may have to do with the side effects of what the patient is already on," he says.

At present, the organizations are involved in an ongoing dialogue with the Joint Commission. They already have had one conference call, and a second was scheduled for late July.

King says JCAHO has received multiple inquiries from organizations around the country, asking how these standards would look in the ED. "They want to know if it applies there, and how JCAHO will be surveying," she explains. "It's caused a lot of anxiety."

Because of the volume of complaints, says King, a workgroup has been assembled to review the requirements and try to determine what needs to be done. In addition to the three emergency organizations, the workgroup includes representatives from the areas of pharmacy, radiology, and hospital administration, she says.

Scalettta says, "We're not sure we're going to be able to change things, but we think they are listening. We'll see what happens."

In the meantime, what advice does he have for ED managers? "If you are going to push back against this, you should do it under the representation of your professional organizations," he advises.

Often, Scalletta adds, hospitals will use as consultants individuals who formerly worked with the Joint Commission. They can advise ED managers as to what will and will not be acceptable when you are not sure if you will be in compliance.


For more information on the medication reconciliation standard and National Patient Safety Goal No. 8, contact:

  • Richard Bukata, MD, Medical Director, The Center for Medical Education, P.O. Box 600, Creamery, PA 19340.
  • Denise King, RN, MS, CEN, 2006 Secretary/Treasurer, Emergency Nurses Association, 915 Lee St., Des Plaines, IL 60016-6569. Phone: (951) 688-2211, ext. 2430.
  • Tom Scaletta, MD, FAAEM, President, American Academy of Emergency Medicine, 555 E. Wells St., Suite 1100, Milwaukee, WI 53202-3823. Phone: (630) 527-5025.
  • Robert Wise, MD, Vice President, Division of Standards and Survey Methods, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.