JCAHO targets medications: What surveyors are asking
JCAHO targets medications: What surveyors are asking
Failing to document the medications a patient currently is taking. Nurses mixing "IV piggybacks." Storing drugs in concentrated form.
These are three things that can get you into trouble with surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), report recently surveyed EDs.
"Medication management was a big topic during our survey at both EDs," reports Kim Colonnelli, RN, BSN, MA, district director for emergency and trauma services for Palomar Pomerado Health in San Diego. The EDs at Palomar Pomerado Health in Escondido, CA, and Poway, CA-based Pomerado Hospital were surveyed in March.
"The physician surveyor spent quite a bit of time in the ED’s medication room, asking questions and discussing medication management with staff nurses," she adds.
Here are actual questions asked of ED nurses by surveyors with the Joint Commission:
• How are medications for admitted patients ordered from pharmacy and stored in the medication room?
Nurses explained that medication orders for admitted patients are faxed to pharmacy. "They send the medications to us, and they are stored in the medication room in labeled bins," says Colonnelli.
• How and where are intravenous (IV) medications prepared?
Joint Commission surveyors are very interested in IV admixtures and pharmacy support, and they want to see that nurses are mixing as few IV piggybacks as possible, says Colonnelli. "We prepare as few IV admixtures as possible," she says. "We do have an area taped off in the medication room for this purpose."
• What kind of support do you have from pharmacy?
"They wanted to know that we had support for admixtures and delivering meds for admitted patients," says Colonnelli. "They are looking for pharmacy to handle medications, as opposed to nursing mixing their own drips."
• How do you ensure that you have the right order and the right patient when giving a medication?
The Joint Commission requires that two patient identifiers are used, such as the patient’s name and birth date, the patient’s name and medical record number, or patient’s name and address.
Nurses told surveyors that they take the order sheet into the medication room to ensure they have the correct patient and medication, says Colonnelli. "The order sheet is compared with the patients’ armbands and nurses are verbally asking the patients their names."
• Are you using medications in the most readily available form?
Joint Commission standards require that emergency medications are available in unit dose, age-specific, and ready-to-administer forms whenever possible. When a surveyor inspected medications in the pediatric code cart at Pomerado, he noticed that a few drugs were stored in concentrated form.
Joint Commission standards state that the medication must be in the most readily available form. "If there is a unit dose available, we should have had that in our cart instead, so that the nurse does not need to dilute a medication during a code situation," says Colonnelli. "We changed the medications put in the pediatric cart due to the surveyor’s recommendations."
• How do you communicate a patient’s medications across the continuum of care?
During an April survey at St. Joseph Medical Center in Towson, MD, the nurse surveyor compared the ED triage nurses’ notes of the patient’s medications and dosages to what the patient said she was taking. Subsequently, the surveyor compared this list to the medications given on the medical/surgical unit, says Vicki Blucher, RN, BSN, CEN, clinical educator for the ED.
"There was an inconsistency in one dosage, which she questioned," she says. "But it turned out to be OK, because the patient was discharged for two days before this particular return to the hospital."
A medication dosage had increased, which was noted on the previous discharge summary from the inpatient side that agreed with the admission history done by the ED nurse. "The surveyor was comparing the patient’s actual pill bottle to what we had on the sheet," Blucher explains. "The ED nurse did state the correct dosage, and it was a good pickup by the nurse, who did actually ask the patient, rather than just write down labels on bottles that the patient gave her."
At Baptist Hospital of Miami, all patient medications are entered electronically at triage and become part of the patient record, says Becky Montesino, RN, ED nurse manager. "So any record the surveyors looked at during patient tracers had this information on it."
Even if the patient is unable to remember their medications or dosages, or a family member is bringing the list later, that information is clearly documented in the record, she adds. "In November 2004, we went live with electronic documentation in our ED," Montesino says. "Had the surveyors come before that, we would not have had it completed. So the screening done on patients is much improved."
• Are medications stored in appropriate areas?
Surveyors wanted to be sure that medications were not in an area where they were available to the public, reports Montesino. "They really watched for that," she warns.
Sources
For more information on accreditation standards regarding medications, contact:
- Vicki Blucher, RN, BSN, CEN, Clinical Educator, Emergency Department, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204. Phone: (410) 337-1524. Fax: (410) 337-1118. E-mail: [email protected].
- Kim Colonnelli, RN, BSN, MA, District Director, Emergency and Trauma Services, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Phone: (760) 739-3320. Fax: (760) 739-3121. E-mail: [email protected].
- Becky Montesino, RN, Emergency Department, Baptist Hospital of Miami, 8900 N. Kendall Drive, Miami, FL 33176. Phone: (786) 596-4489. E-mail: [email protected].
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