Reader Question: Automated dispensing machines need approval
Reader Question: Automated dispensing machines need approval
Approval required for first dose of medications
Question: We have implemented an automated dispensing system for medications on some nursing units, and they are tremendously helpful in streamlining our processes. The pharmacy controls the machines, but now we’re confused about whether we’re violating Joint Commission on Accreditation of Healthcare Organizations standards when a nurse is able to obtain the first dose of a medication without pharmacist review of that particular prescription. Do we still need to get pharmacist review?
Answer: Yes, you still need to have a pharmacist approve the first dose before the nurse obtains it, even though that may seem to run counter to the convenience promised by the automated dispensing units. Lucille Skuteris, associate director of the standards interpretation group for the Joint Commission, tells Hospital Peer Review that the use of an automated dispensing unit does not change the requirements for pharmacist oversight. TX.3.5.2 requires that "Pharmacists review all prescriptions or orders," and Skuteris says that includes any medications dispensed by automated machines.
"It’s an issue of patient safety. There needs to be some sort of control regardless of where the meds are coming from," she says.
Skuteris says that two exceptions are noted in the intent section of the standard. The first involves situations in which the physician controls the ordering, dispensing, and administration of the drug, most commonly in the operating room, endoscopy suite, and emergency department. The pharmacist review also is not required in an emergency situation, when the review would be time-prohibitive. STAT orders or any other in which the patient’s health could be compromised by waiting for a pharmacist review would meet the criteria. But she adds that not all first doses would meet those criteria.
If a surveyor determines that nurses are obtaining medications prior to a pharmacist review in routine situations, a Type I recommendation will be made for failing to meet standard TX.3.5.2. The Joint Commission makes no distinction, Skuteris says, between automated dispensing machines and nonautomated floor stock when assessing compliance with the standard.
Some hospitals address the problem with a "profile-interfacing" system that requires all new orders to be entered into the pharmacy system; only then is the nurse able to access the medication in the dispensing machine, Skuteris says. Nurses usually can override such a system, so it is far from foolproof, she notes.
The Joint Commission recommends that providers implement a policy and procedure specifying when nurses can access the medications from the machine prior to a pharmacist review. Nurses should be trained in the policies and understand that they should override the pharmacist review only in the most serious of cases. Pharmacy also should audit compliance with the policy. When it is necessary to bypass the pharmacist review, the Joint Commission recommends having a second nurse verify the order and the medication prior to administration unless there is a true emergency.
If an automated dispensing unit is in use, Joint Commission surveyors usually will ask nurses on the floor to describe the circumstances in which they take medications from the machine prior to a pharmacist’s review. A good response is "only for STAT orders and when the clinical need of the patient demands immediate administration of the drug, such as the administration of morphine to a patient in pain or the administration of ranitidine to a patient in gastric distress," Skuteris says. "For every first dose," is not a good response.
[For more information, contact:
• Lucille Skuteris, Associate Director, Standards Interpretation Group, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5909.]
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