Catalog Number : ncd1148
Title : Keys to Complying with the Latest Joint Commission Medication Management Standards
Speaker : Sue Dill

Webplay Recording Date : 5-6-2010
Webplay Price : $ 200 for two weeks viewing

Webinar Purpose:

Medication errors are the number one cause of medical errors in hospitals. The Joint Commission medication management standards were drafted with this in mind. This program will cover the 2010 chapter of the Joint Commission’s medication management chapter (21 elements of performance), including four new changes effective July 1, 2009. These changes continue into 2010. The TJC focus is now on medication safety and reduction of errors. Medication management was a new chapter that the Joint Commission came out with in 2004 and it has been amended every year since. This year two of the top ten standards that hospitals are found to be out of compliance are related to medication management standards. Joint Commission does a medication management tracer during the survey process and medication management is one of the fourteen priority focus areas.

This section is very important for any hospital to know whether accredited by TJC or not. This chapter has eight sections which are especially important to pharmacists, nurses, physicians and any one involved in the medication process. This program will cover selection and procurement, storage, ordering, transcribing, preparing and dispensing, administration and monitoring of medications.

CMS, in its hospital conditions of participation, have adopted one of the Joint Commission’s medication management standards for self administration of medication. Joint Commission has adopted many of the CMS hospital CoP standards that will be surveyed after July 1, 2009 and in 2010. Medication management is a hot issue with both the TJC and CMS. Come learn how to make sure you understand the standards and that your hospital is in compliance.

Target Audience:

This program is for anyone involved in the medication process especially pharmacists, physicians, nurses and others. Risk managers, hospital attorneys, compliance officers, patient safety officer, Joint Commission coordinators and quality and performance improvement staff, chief nursing officer, policy and procedure committee members, case managers, nurse educators, nurse managers, and others who participate in the medication process should attend.

Webinar Objectives:

• Recall the broad definition by TJC of what constitutes a medication which includes IV, blood, vaccines, vitamins, over the counter medications and herbals
• Describe the TJC and CMS hospital requirement for self administered medications
• Discuss how your facility needs to have a list of high risk medications and recommendation for this policy

Webinar Topics:

• TJC MEDICATION MANAGEMENT STANDARDS
  • Definition of medication
  • FAQs on medication management
  • July 1, 2009 changes to five standards
  • Survey process
  • Overview of medication management standards
• Planning MM.01.01.01, MM.01.02.01, MM.01.01.03
  • Planning the MM process
  • Policy required
  • High alert medication
  • Look-alike/sound-alike medications
• Selection and Procurement MM.02.01.01
  • Criteria to select medications
  • How to select medications-formulary
  • Monitor response to first medication
  • Process to approve drug not on list
  • Shortages of medications and process
  • Nursing need for information on how to monitor the drug
  • Annual review of the list
  • Written substitutes process
• Storage-MM.03.01.01, MM.03.01.03, MM.03.01.05
  • Storage of medications
  • Storage of controlled substances
  • Inspection of storage areas
  • Policy on control of medication and accounting
  • Emergency medications
  • Expired or contaminated medications
  • Medication brought from home
  • Unit dose or most readily available form
  • Crash cart standard
  • Restocking crash carts
  • Availability of emergency medicines
  • Rule of 6 not allowed
  • Concentrated electrolytes
• Ordering and Transcribing MM.04.01.01
  • Policy requirements
  • Minimize verbal orders
  • Weight based dosing for pediatric patients
  • Flu and Pneumovax orders
  • Ordering only medications needed to treat patients
  • Documented diagnosis for each medication ordered
  • Medication orders are written clearly
  • What must be in policy on ordering and transcribing
  • What actions to take if orders are illegible
  • PRN orders, hold orders
  • No resume preop orders or home meds
  • Titration orders and taper orders
  • Range orders
  • Verbal orders
• Preparing and Dispensing- MM.05.01.01, MM.05.01.07, MM.05.01.09, MM.05.01.11, MM.05.01.13, MM.05.01.17, MM.05.01.19 (MM.05.01.15 N/A to hospitals)
  • Pharmacist first review of drug order
  • Night cabinet standard
  • What must be reviewed by pharmacist
  • Safe preparation of medications
  • Automated dispensing units
  • What to do when pharmacy is closed
  • Medication errors
  • Separate area for nurses to prepare medications
  • Concerns must be addressed by prescriber
  • Medication preparation requirements
  • Laminar airflow standards and USP requirements
  • Medication labeling (also 2010 NPSG)
  • Dispensing requirements
  • Drug recalls
  • Returning meds to the pharmacy
• Administering- MM.06.01.01, MM.06.01.03, MM.06.01.05
  • Safely administering meds
  • Policy requirements for administration
  • Who can administer medications, blood, chemo
  • What to do if adverse drug reaction
  • Visually inspecting the medication
  • What a nurse must do if giving new medication
  • How to document process when nurse gives new med
  • Self administered meds
  • Investigational drugs
• Monitoring MM.07.01.01, MM.07.01.03
  • Monitoring side effects of medications
  • Monitor patient’s response to medications
  • Adverse drug events/medication errors
• Evaluation- MM.08.01.01
  • Evaluation of system
  • Analyzing data
  • Evaluating literature for new technologies
  • Best practices
  • Bar coding
  • Evaluation of system for risk points
  • Consider FMEA on medication process
• TJC 2010 NATIONAL PATIENT SAFETY GOALS RELATED TO MEDICATION MANAGEMENT STANDARDS
  • Medication reconciliation
  • Anticoagulants
  • Labeling of medications
• Things that will be discussed in separate webinar on CMS CoP on Medication
  • Verbal orders
  • Pharmacy policies required
  • Resume pre op orders prohibited
  • Multidisciplinary committee
  • Review of meds by pharmacist
  • Medicines brought in
  • Locked storage area
  • What to do when no pharmacist on duty
  • Medication errors
  • Administration of drugs
  • Meds within 30 minutes of scheduled time
  • Written order for medications
  • Flu and pneumovac exception

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.