Catalog Number : ngd1773
Title : CMS CoP New Revised Standards for Hospitals: IV, IV Medication and Blood Transfusion Guidelines
Speaker : Sue Dill

Webplay Recording Date : 9-6-2011
Webplay Price : $ 200 for two weeks viewing

Webinar Overview:
Every hospital that received Medicare and Medicaid reimbursement should be aware that CMS amended several important section to the hospital conditions of participation (CoP) manual including clarifications to the section on nursing requirements related to blood transfusions, IVs, and intravenous medication. This means hospitals will need to update their policies and procedures and revise their education related to these issues. This memo was issued May 13, 2011 and updated May 20, 2011. This section revises tag numbers 409, 508, 1133, 1134, and 1164.

The memo clarifies the training requirements for nurses and other personnel who administer blood transfusions and intravenous medications. It also amends the section to ensure there is immediate reporting of drug errors, adverse drug events (ADE) and incompatibilities. This program will also cover two minor issues related to respiratory therapy and rehabilitation. Previously, CMS only allowed doctors to order respiratory or rehab therapy. Now, others like Physician Assistant (PA) or a Nurse Practitioner (NP) can order if within their scope, allowed in hospital policy and credentialed by the hospital.

Target Audience:

• Chief Nursing Officer
• Chief Medical Officer
• Compliance Officer
• Risk Managers
• Nurse Educators
• Nurses involved in IV medications or transfusions
• Physicians involved in IV medication or transfusions
• Patient Safety Officer
• Joint Commission and Regulatory Affairs Director
• Blood bank supervisor and staff
• Nurse managers
• Chief operating officer
• Human Resource Director or staff
• PI Director or staff

A few of the topics to be discussed:

• Introduction
• Blood transfusion and IV medications
  • Administer in accordance with state law
  • Approved MS P&P required
• Specialized training required
  • During orientation
  • During continuing education programs
• Documentation of competence in HR file
• Training content
  • Must be based on national standards
  • Fluid and electrolyte balance
  • Venipuncture techniques, including both demonstration, and supervised practice
  • Blood transfusion training: blood components
  • Blood administration procedures based on hospital policy
  • Requirements for patient monitoring, including frequency and documentation of monitoring
  • Process for verification of the right blood product for the right patient
  • Identification and treatment of transfusion reactions
• Scope of practice for IV medications and transfusions
• Survey procedure
• Drug errors, ADE, and incompatibility reports to the physician
• When must immediate reports be made
  • Significant harm immediate
  • No or insignificant harm
  • Outcome of error is unknown
• Covering physician notification allowed
• Still requires notification of attending physician
• Hospital P&P required on reporting
• Identify events that must be reported to PI
• Definitions of drug error, ADE, and drug incompatibilities
• PI program must tracker and report errors
• Must include near misses and suspected ADRs
• Medication error P&P required
• Non-punitive environment
• Broad definition of medication error
• PI program to include benchmarks of ADE and errors
• National reporting encouraged
  • ISMP medication error reporting system
  • FDA MedWatch program
• Survey procedure
• Rehab Services and Respiratory Therapy require order
  • Order must be within scope of practice
  • Must be privileged and credentialed
  • Hospital P&P
  • Survey procedure
  • Order must be documented in the medical record
  • Plan of care requirements
  • Staff must be qualified
  • Survey procedure

Webinar Objectives:

• Recall that CMS revised the CoP in May of 2011 regarding IV medication and blood transfusion
• Discuss that CMS requires immediate reporting of medication errors, adverse drug events and incompatibilities
• Describe that CMS made revisions to reflect regulatory changes governing orders for respiratory care and rehab

Nursing Contact Hours:

• Nursing participants: Instruct-online has approved this program for 1.8 contact hours, Iowa Board of Nursing Approved Provider Number 339.
• All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 1.5 Hour Attendance Certificate for each program.

Completion of offering required prior to awarding certificate.

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.