Comply with JCAHO’s goal to label all medications

Many organizations are not in compliance

The Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) National Patient Safety Goal requiring all medications to be labeled sounds simple enough, but it’s proving to be difficult for many organizations.

"I think the biggest challenges for an organization center around the back-table labeling of syringes and containers," says Susan Mellott, PhD, RN, CLNC, CPHQ, FNAHQ, who is CEO of Houston-based Mellott & Associates. "While the operative areas may be already doing this, this has not always been occurring outside of those areas."

Even within the operative areas, staff may not have been labeling syringes or basins that contain normal saline or other "non-medication" fluids, says Mellott. "I am sure that a clarification will be coming out stating that any procedure area will have to comply with this goal. If there is not such a clarification at this time, organizations would be well advised to implement this goal in the non-perioperative settings, as it is really best practice," she says.

Newly revised requirements for the safety goal have been changed to make them more consistent with the requirements in Medication Management standard MM 4.30. The new requirements are as follows:

  • Labels include drug name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.
  • All labels are verified both verbally and visually by two qualified individuals when the person preparing the medication is not the person administering the medication.

The revision deletes a previous requirement to include on the label the initials of the person preparing the medication or solution and the date of preparation. Neither of these items is required under MM 4.30. After review by the Sentinel Event Advisory Group, it was determined that the deleted requirements provided "no additional safety to the preparation and labeling process," according to a JCAHO announcement.

Inventory the types of fluids and medications used during procedures, and then obtain preprinted labels for these solutions, recommends Mellott. "There could be a standard set for the facility and specialty labels for areas that require more labels than the common ones, such as the cardiac catheterization lab," she says. "The organization should then monitor for compliance after implementation."