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Case A:

Our small, rural hospital (under 100 beds) was recently surveyed, quite unexpectedly (6 months early) by JCAHO.  The surveyors were thorough, and very nice.  No policies were examined.  The main medication management and National Patient Safety Goal focuses were on medication reconciliation, abbreviations (don't forget, just one on a standing order is automatically a requirement for improvement), out-of-date drugs (they were thorough in the operating rooms and with anesthesia carts), and labeling syringes.  The first day the physician surveyor quizzed the pharmacy associates on procedures used, and asked open-ended questions so he would know if the medication management standards were familiar to the staff.  He asked what we were doing about noise control.  Also, he said to be prepared for 3 more mandatory do-not-use abbreviations.

Case B:

Our hospital was surveyed last week (09-17-06 thru 09-19-06).  The hospital received 7 RFI’s, 3 of which were related to medication management:

1)                   NPSG #2:  “Do Not Use” abbreviations were found in 8 records that were reviewed.  This was primarily QD and MS0₄ .  The physician surveyor noted that although the pharmacy was attempting to manage the process, the medical staff needed to be actively involved in providing support for the initiative, through peer pressure, etc.

2)                   MM 2.20:  “medications are stored under necessary conditions to ensure stability”:  The physician surveyor disagreed with our method of providing temperature readings for medication refrigerators located in areas that are not open 7 days per week.   We utilize a minimum – maximum recording thermometer, and read it Mon – Fri, and review the recorded minimum – maximum each Monday.  The surveyor specifically stated that the insulin in the medication refrigerator in question might not be good, since we did not physically monitor the temperature on weekends.  Even though I pointed out that most insulin preparations are stable at room temperature for 28 – 30 days, he persisted with his claim.

3)                   MM 3.20:  “minimize the use of verbal and telephone orders”:  The surveyors indicated that there were too many verbal and telephone orders in the records reviewed.  They felt that the hospital was allowing physicians to delegate order writing to others on a routine basis; and that the standard provides for this only in cases of emergency.

Areas of interest during the survey included:

1)                   Medication Safety (NPSG #3) – during the Medication Management review, we were required to present a scenario where we had utilized FMEA, etc., to evaluate and improve medication usage for high risk / high alert medications, and for look alike / sound alike medications.  Absent in the Medication Safety review were any questions about the Rule of Six usage in the NICU.

2)                   Medication Reconciliation (NPSG #8) – reviewed our process thoroughly, and found it to be acceptable

3)                   Pharmacy tour / review – during this review with the physician that lasted one hour, the surveyor covered the following items:

•         Review of safety and security processes (alarms, cameras, etc) for the pharmacy department and staff members.

•         Review of planning and implementation of USP <797>, and JCAHO MM 4.20 requirements

•         Review of ADM (Pyxis®) policy and procedures for user access, override functions, first dose review by pharmacist, discrepancy audits, etc

•         Formulary management and the role of the pharmacy in P&T committee processes

•         Pharmacy based auto-substitution policies

•         Pharmacy based medication management activities (kinetic dosing, CrCl monitoring, IV to oral conversions, etc)

4)                   Pharmacy and Therapeutics committee review:  The physician surveyor interviewed the P&T Committee chair, and discussed the role of the physicians on the committee; discussed challenges being faced by the committee; inquired about the level of support from hospital administration; asked if we had any questions about the JCAHO review process.

5)                   Items that were NOT discussed or addressed by the surveyors during the hospital’s review included:

•         Competency reviews for staff members

•         Sample medications

•         Emergency drug supply (crash cart) management

•         Medication error reporting

•         Adverse drug reaction reporting

•         Investigational drug procedures

•         Contrast media order review

Case C:

We received 6 total RFI's, 2 of which were related to medication management and none directly related to pharmacy.

The 2 medication management RFI's:

1) 4.10

We had an order for NSS @ 100ml/hr.  It was picked up on a chemotherapy patient and it was definitely a case of us shooting ourselves in the foot.   They questioned nursing about the clarity of the order.   The chemo nurses knew the order was for one bag only as hydration during chemo, but it was not written x 1, so the nurse said the MD did not write for one bag but they knew from experience what was meant.  In reality, the surveyors were interested if we knew the NSS was by the IV route, since it was not stated.  They did not even realize it was a 1 bag order.

Additionally, on another chemo patient, the computerized chemo orders we receive from our oncology group do not always include the diluents and rate of administration.  In most situations they feel pharmacy can better decide on thing like this, especially since the MD may not know.  In reality though, if an error is made and the order was not complete we are probably liable.   They really got on the responsibility of the MD as part of this RFI. Our mandate is to work with them to improve this process and monitor for 100% compliance.

2) 2.20

They found a hyperthermia cart in the OR center-core that was not locked.  Even though this is a restricted area and the cart is routinely checked for outdates, because housekeeping is in the area, the cart must be locked.

We were happy with the overall survey.