CMS rewrote 10 of the 18 tag hospital pharmacy sections November 20, 2015. As a result, there has been increased scrutiny of the standards and an increase in the number of deficiencies. This should be on the radar screen of all hospitals. Information will be provided on the top problematic pharmacy standards by CMS. There have been many recent changes in the nursing section that address medication usage which will be discussed as well.
Target Audience:
This program is for anyone involved in the medication process especially pharmacists, chief pharmacy officer, physicians, all nurses, patient safety officer, nursing supervisors, nurse managers and others. Risk managers, hospital attorneys, compliance officers, Joint Commission coordinators and quality and performance improvement staff, chief nursing officer, chief medical officer, chief operation officer, policy and procedure committee members, case managers, nurse educators, nurse managers, compliance officer, director of regulations, Joint Commission director and others who participate in the medication process should attend.
Webinar Objectives:
recall that all hospitals that receive Medicare/Medicaid reimbursement must follow the medication guidelines for all patients
discuss that CMS has requirements on BUD and compounding
recall that CMS has a number of required pharmacy policies and procedures
describe that CMS requires a policy for high risk drugs such as double checks or dose limits
Webinar Overview
- Pharmaceutical Services requirements
- Qualified pharmacy director
- How to locate the CMS manual
- OIG Report on Oversight of Compounded Pharmaceuticals Used in Hospitals
- 55 areas surveyors should look at
- ASHP and ISMP on compounding
- CMS final infection control worksheet: safe injection practices, microbial stewardship, and MDRO
- Ten final tag number changes in 2016
- Proposed changes: antibiotic stewardship program requirements for 2017
- ISMP IV Push Guidelines
- CMS and TJC Antimicrobial standards and issues
- CDC vaccine storage document
- Common problematic pharmacy standards
- Standards of care
o ISMP, USP, ASHP, APA, FDCA, etc.
- Recent CMS Memos: safe injection practices, infection control breaches, luer misconnections, insulin pens
- CMS 45 page memo regarding pharmacy and medication changes and changes final now
- Nursing tag 405 and additional resource
- Compounded medications and BUD
- Safe injection practices
- Compounded sterile preparations(CSP)
- Immediate-use CSP and one hour rule
- Meeting the needs of patients
- What is included in pharmaceutical services?
- Medications must be available timely
- Condition or standard level deficiencies
- Medications timing changes
- MS role in developing P&P including to minimize drug errors
- Functions of pharmacist
- Required P&P
- Flag new types of medication errors
- High alert medication
- Limiting number of medication related devices
- Pharmacist on call if not open 24 hours
- Standardization of prescribing and communication practices
- Weight based dosing
- Availability of patient specific information
- Abbreviations, look alike-sound alike drugs
- Pre-printed order sheets
- Voluntary non-punitive reporting system
- Weight based dosing for pediatric population
- Incorporation external alerts
- P&P required by hospitals
- Policy to minimize drug errors
- Storage of drugs
- Pharmacy director role in P&P
- Drug storage of medications and biologicals
- Dispensing and administration of medications
- Pharmacist job description
- Pharmacy personnel requirements
- First review of new medications by pharmacy
- Policy to address medications brought in
- Monitoring effects of medications
- Investigation drug policy
- Recalled or discontinued drugs
- Compounding of drugs
- The Drug Quality and Security Act (DQSA)
- Outsourcing facilities
- Use of compounding pharmacies
- Medications compounded by hospital pharmacy
- Compounding practices and quality control
- BUD, packaging, and labeling of medications
- Locked storage areas
- OR anesthesia carts and ASA guideline
- Medication and crash carts
- Patient self-administration of drugs regulation
- Outdated or mislabeled drugs
- When pharmacist not on duty
- Night cabinet standard
- Automated stop orders and policy
- Medication error and near misses
- Proactively identify medication errors
- Indicator or trigger drug review
- Drug interaction information
- Formulary
Contact Hours:
- Nursing participants: Instruct-online has approved this program for
2.4 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
2 Hour Attendance Certificate for each program.
Completion of offering required prior to awarding certificate.
Phone
(319) 626-2302