Help pharmacists meet new medication standard

Motivate staff and managers with safety data

Two things are certain: The Joint Commission on Accreditation of Healthcare Organizations’ newly revised medication management standards will be a key area of focus during surveys, and complying with the new requirements will call for sweeping changes throughout your organization.

"The new standards are a lot more prescriptive than they have been in the past," explains Tom Vogt, RPh, MS, manager of pharmacy services at Overlook Hospital in Summit, NJ. "Many require documentation at least 12 months prior to the survey. There is a lot of work that has to be done if you are going to track all these different elements."

In contrast to previous requirements, the new standards are much more specific, notes Jeffrey A. Patchett, RPh, MBA, director of pharmacy services at NorthEast Medical Center in Concord, NC. "The focus on safety is admirable, and it is satisfying to finally see the Joint Commission recognize the value that the pharmacist adds to the process," he says. "But we were not ready for the all-encompassing nature of the new standards."

From the pharmacy director’s perspective, you are invaluable to meeting this challenge by providing insight for process changes and data management, Patchett stresses. "Quality managers can help us convince administrators that many of the changes really are for safety, not just some overreaction to a regulatory agency. At our facility, it has been very helpful to have someone other than the pharmacy director convincing staff that the change is for safety."

As a quality manager, the most effective thing you can do to help pharmacy directors comply with the standards is to continually educate staff, Patchett advises. He says presenting safety data to both unit staff and managers is the best motivator.

"When our staff saw the data from our bedside bar-coding system, all of our eyes were opened to the types and number of medication errors that could be happening. I think all of us adopted a completely different view of safety when we saw the facts," Patchett notes.

The data collection process first looked at prevented errors, which are collected and tabulated by the type of error, the unit, and the drug.

A prevented error occurs when a transaction is attempted, and the bar-coding system (Bridge MedPoint, manufactured by Solana Beach, CA-based Bridge Medical) gives the user a warning that he or she is about to do something wrong, and the user stops before the wrong drug or dose is given. The number of prevented errors exceeded 500 per month even after the data were scrubbed, Patchett reports. Further analysis revealed which drugs and which processes were causing the most prevented errors.

Next, potential errors were tracked. These are recorded transactions in which the system gives the user a warning that he or she is about to do something wrong and the user does it anyway. However, many of these potential errors actually are harmless, such as giving a drug in 59 minutes which is outside a one-hour limit. "They are considered potential errors, because we really don’t know that they’re errors until we go back and analyze them," he explains.

Error prevention

Staff were disturbed to discover many examples of drugs that weren’t similar in name, form, or therapeutic indication being scanned for another dose due. "We were astonished at how frequently a nurse would bar-code scan a drug that was in no way similar to the drug prescribed," Patchett says. "Fortunately, the bar-code system stops the vast majority of those actions. We can only imagine how many times drugs were given in error."

The data were gathered by a nursing analyst, presented in tabular and graphical form to the facility’s medication event subcommittee, and shared with unit managers. High-volume, high-risk prevented errors were identified, and the committee — consisting of representatives from pharmacy, nursing, risk management, and quality improvement — made recommendations for change. "When the change was presented to the staff, the reason for the change was also presented," he adds.

Ideally, potential errors should get more attention early on and should be presented to unit staff, Patchett argues. "The prevented errors deserve attention but not necessarily immediate action. As the analysts learned to scrub the data, we were able to pull out errors and use them for education."

The data from the bar-coding system currently are being integrated with the manually reported medication errors to develop a more aggregated approach to error evaluation, Patchett reports.

Here are some of the new requirements of the medication management standards, with strategies for each:

The definition of "medication" is expanded.

"It used to be that a medication’ was merely that. Now, that definition has expanded enormously," Vogt says.

The new standards include prescription and over-the-counter drugs, herbal supplements, vitamins, "nutraceuticals," vaccines, diagnostic agents, contrast agents, radiopharmaceuticals, blood derivatives, and intravenous (IV) solutions. "It doesn’t specify with additives’ — therefore d5W is included," he adds.

This brings many new areas under the umbrella of compliance, including radiology, laboratory, food services, nuclear medicine, and even the hospital’s blood bank. "It’s not just a pharmacy standard anymore," Vogt says.

At Overlook Hospital, a medication process resource manual was created to address the new agents now falling under the standards, including ordering privileges, initiating, transcribing, reordering, and bedside medications.

The original manual was broken down into categories of "decide," "order," "distribute," "administer," "monitor" and "evaluate," but it is being rearranged to follow the new Joint Commission standards. "There are eight different sections of medication management," Vogt explains. "We will separate out the policies and procedures for those eight sections to make a true crosswalk."

At Northeast Medical Center, a committee of managers and physicians was formed so that all affected areas could give input. "We feel that most of these new standards have a broad, sweeping impact and require many different disciplines coming together to successfully achieve compliance," Patchett notes.

The theme that needs to be conveyed to everyone is that these changes are for patient safety, he says. "They may seem inconvenient at first, but if we prevent errors, all will be worth it."

When unapproved abbreviations are used, actions must be documented.

The standards don’t specify what kind of documentation is needed to address the use of unapproved abbreviations, Vogt notes. "But you have to prove that for the previous 12 months, you did do something about it." The hospital’s information system flags all orders with unacceptable abbreviations, the physician is contacted to clarify the order, and it is documented that the call was made, he adds.

"We are tackling the abbreviation patient safety requirement by collecting copies of any correspondence with unapproved abbreviations and routing those back through the offender’s department for data collection and to be reviewed," Patchett explains.

The pharmacy must compound all IV medications in the organization.

"The new standard made us look around to see what we took for granted. We found many areas making IVs that we didn’t even think about," he says. "We knew they were there, but the nurse was trained to make IVs in those areas, and we allowed the medications to come from floor stock or Pyxis [dispensing system]."

These areas included labor and delivery, the same-day treatment center, emergency care center, and the preoperative, postoperative, and intraoperative areas. All now fall under the new standards requiring that all IVs be made by the pharmacy unless the additional time required could adversely affect the patient’s outcome, Patchett adds.

"The Joint Commission is taking the viewpoint that the double-check process — of a technician making the product and a pharmacist checking the product — is worth the effort," he notes. "They are apparently concerned about the environment in which a nurse may make the IV on the unit."

All medication orders must be reviewed by a pharmacist.

"The intent is rooted in patient safety, but the application is very difficult," Patchett says, explaining that either additional manpower will be needed or a burdensome workload will be placed on pharmacy staff. "Right or wrong, there are many medication orders written and given that currently don’t receive pharmacist review in most hospitals." The new requirements may wreak havoc with turnaround times and, in turn, negatively affect customer satisfaction, he adds.

Many areas are not used to working with the pharmacy to process their medication orders, such as the typical labor and delivery department using a limited number of different medications. "Historically, the pre-term patient’s medication needs have been managed by the nursing staff and physicians present on the unit," he notes. "Now, we are challenged with looking at each case and deciding if the time it takes to review, order, and have the pharmacy make the IV will adversely impact the patient."

Another example of a potential problem area is the facility’s outpatient treatment area, where patients regularly come for an IV or injectable medication. Often, a blood level or a physiological monitor must occur before the medication may be given. Therefore, until that monitoring step occurs, the medication order cannot be written, reviewed by the pharmacists, prepared, and sent to the unit.

"Everyone is patient when the product is an IV product that requires compounding," Patchett adds "However, if it is an anticoagulant subcutaneous dose, waiting 30-45 minutes for this process to occur seems wrong. It feels like poor customer service to make someone wait for an injection that takes minutes to give."

Previously, this area was considered as having physician oversight since the monitoring occurs before the order is written, he notes. "In many situations, the drug would then come from an automated dispensing cabinet. With the new standards, the pharmacist must review the order before it can be administered."

[For more on the new standards, contact:

Jeffrey A. Patchett, RPH, MBA, Director of Pharmacy Services, NorthEast Medical Center, 920 Church St. N., Concord, NC 28025. Phone: (704) 783-1566. Fax: (704) 783-3157. E-mail:

Tom Vogt, RPh, MS, Manager, Pharmacy Services, Overlook Hospital, 99 Beauvoir Ave., Summit, NJ 07901. Phone: (908) 522-2223. Fax: (908) 522-0660. E-mail:]