Accreditation Field Report: Survey finds problems with nonurgent medications

Survey was very patient-focused’

A recent four-day Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey at United Regional Health Care System in Wichita Falls, TX, was "very patient-focused, with direct caregivers much more involved," reports Darlene Adams, RN, MSN, the organization’s patient care safety/quality management officer. "The surveyors had reviewed our prior survey results, priority focus areas, clinical service groups, core measures, and demographics in our application — so they had a lot of information," she says. "They knew where they wanted to go and what they wanted to see from Day One."

For the first time, staff felt they really were a part of the survey process, Adams says. "Surveyors did not want to talk to managers or directors," she says. "I would say if anyone’s not doing mock tracers, they need to be doing that. We did a lot of mock tracers, and it really helped the staff a lot."

In retrospect, the mock tracers would have been more effective if a better survey tool had been used, Adams notes.

"We had a tool that wasn’t as thorough as the one the surveyors had," she says. "For example, we covered the safety goals but not as extensively as they did. They had a lot of requirements for documentation, and information on the different provisions of care looking specifically for cultural issues and education, which we didn’t have."

Here are some of the lessons learned from the survey process:

You’ll need to demonstrate intervention if legibility is a problem.

Surveyors specifically pulled a physician’s credentialing file because they couldn’t read his or her handwriting and wanted to see if the organization had addressed the problem. "It hadn’t been identified yet, because we had just only implemented our legibility policy," Adams explains.

The policy states that if three people cannot read an order, it will not be carried out until it’s clarified, she says. The physician will be called to clarify this order. During quarterly chart review, if legibility still is identified, the physician is notified by a letter. If the legibility problem continues, another letter is sent with a copy to the chairman, and the next step is a consultation with the chairman, Adams notes.

Ensure documentation is adequate.

"There was less emphasis on paper and more on process, but open charts and documentation was still closely reviewed," she continues.

Surveyors looked for history & physicals, use of do-not-use abbreviations, and documentation of verbal orders and if they were read back. "They would ask the nurse how the verbal orders were handled. They would be looking for I wrote it down and read it back,’ not I repeat it back,’" Adams says. "That was not good enough."

Make sure your documentation of a timeout is consistent.

Surveyors wanted to see that any unit, which needed to do a timeout, had a place to document this.

In the operating room and cardiac catheterization lab, the forms had this, but in the emergency department (ED) and critical care units, they did not. "We made that change, and added timeout’ as a prompt with a place to document this on all forms using the same verbiage," says Adams.

Look at the process for checking out-of-date supplies, drugs, test strips, and cleaning solutions.

In the radiology area, surveyors wanted to see if employees knew the manufacturer’s recommendations for all the test solutions used for ultrasound, as to when they need to be tested and replaced, she continues.

Testing must be done at required intervals for smoke and fire dampers.

During a recent construction process, certain areas were slated to be renovated but were put on hold, which meant that the required testing of smoke and fire dampers fell through the cracks. "We didn’t have the right documentation to show that they have been tested at specified time frames, and it’s going to cost us $100,000 to fix that," says Adams.

Nonurgent medications in the ED must be reviewed by a pharmacist.

According to JCAHO’s new medication standards, if a medication is urgent, emergent, or there is a physician in control of the medication, then it doesn’t have to be reviewed by a pharmacist. However, even though a dedicated physician always is present in the ED, the surveyors stated that a percentage of ED patients have nonurgent medications, and those nonurgent medications need to be reviewed by pharmacy, and the physician was not "in control" in this case.

"This was a surprise," says Adams. "We did try to discuss that point, but we did get a requirement for improvement. That was a big, big project. Now you are adding time to the process, and ED patients have to wait. Another problem was that we only had one pharmacist at night."

To resolve the problem, at least two more pharmacists will be added, with an additional eight hours of work per day, says Adams. "We also had to change the forms that are scanned from the ED to the pharmacy and have to buy a stand-alone computer program to help the pharmacists reviewing the medications contraindications," she says.

First, the nonurgent medications were identified, with each having to be reviewed by a pharmacist. Nurses only can override this for three reasons: It would harm the patient by not giving it prior to review; the physician was present and requesting the medication, which would imply he or she is in control; or the medication is part of a protocol, such as aspirin for acute myocardial infarction.

For the nonurgent medications, the patient’s chart must be scanned as "stat" to the pharmacist, who has to review it immediately along with the patient’s height, weight, allergy and medication list, and reason for being in the ED. "Then, once they approve the medication, they have to notify the nurse that it’s in the profile, so this delays the patient’s leaving," she says. "Then if the medication is dispensed, they have to label it and send it up by runner or pneumatic tube so that the patient gets the proper instruction."

Currently, a 24-hour retail pharmacy is expected to open across the street from the hospital, so this may alleviate the problem, since not as many non-urgent medications will be dispensed through the hospital pharmacy, says Adams.

With longer length of stay times in the ED, patient satisfaction is likely to decrease, she adds. "If the medication needs to be delivered, we hope we can get it to the ED within 30 minutes, but that may be unrealistic."

[For more information about the organization’s JCAHO survey, contact:

Darlene Adams, RN, MSN, Patient Care Safety/Quality Management Officer, United Regional Health Care System, 1600 10th St., Wichita Falls, TX 76301. Phone: (940) 764-3062. E-mail:]