Medication management deficiencies were among the most often cited elements during 2020 surveys. Do you have systems in place to ensure patient safety and regulatory compliance?

How do you store medications? Do you know what to do with high-alert and look-like-sound-alike medications? How about hazardous medications? Who in your facility is responsible for keeping up with all the clinical and regulatory changes? In this post we discuss some of the areas to focus on and questions you will need to answer during your next certification or accreditation survey.

The Joint Commission recently published a list of the Top 5 most challenging requirements for 2020 and not surprisingly, various aspects of medication management made up a big portion of the areas found to be non-compliant. As we all know, many of the standards of the licensing and accrediting agencies often overlap. Take for example infection control; not only does it impact cleaning procedures, disinfecting equipment, hand hygiene and antibiotic stewardship, but it is also directly tied to medication management. How? Have you heard of the “one-hour rule” for pre-drawn syringes? The main reason it exists is because of infection control. We could do several posts on infection control alone, but in this post, we will address standards that specifically target  medication management.

What are the most common medication management related deficiencies?

1. The organization does not safely manage high-alert and hazardous medications. These medications are often involved in errors that lead to patient harm. Do you have a plan in place to manage them? Have you created and posted your list? How are you highlighting these medications when stored, to minimize errors? How do you manage additions and removals from your formulary?
2. The organization has not addressed the safe use of look-alike/sound-alike medication. Have you developed a list of look-alike-sound-alike medications that is specific to your facility? Is it posted? How are medications handled in storage and during administration? How do you handle sample medications? Is your list reviewed and updated annually?
3. The organization does not safely store medications. Are you storing medications according to manufacturer’s specifications? How are you securing medications when they are not attended by a licensed staff member? How are you storing controlled substances? What steps have you taken to follow state and federal law? Do you use prescription pads? Do you have a process in place to handle prescription pads? Does your process meet the current standards? What are you doing with expired medications? What about expired controlled substances? Beyond patient safety and survey issues, do you know what to do with medications to avoid legal issues and liability?
4. The organization does not safely administer medications. Let’s start with patient allergies. Have they been documented in a consistent and prominent location in the patient’s chart? When it comes to administration, have the medications been prepared properly? How about labeling? Part of safely administering medication involves labeling them correctly. Do you know what elements are required on a label? How are you managing single dose versus multi-dose vials? Is there a difference? What about medication preparation areas? Do you have them? What are the standards and how do they differ for medications prepared at the patient’s bedside or in the operating room?

By now you realize that the list of questions you must be prepared to answer during your survey is quite long, and this is only the tip of the iceberg. Even if you have a dedicated staff member managing medications in your facility, it is nearly impossible for them to keep up with each of these issues unless that is their expertise and their only job function. The best way to cover your bases is to have someone on your staff who will champion this cause and rely on an expert consultant pharmacist to do the heavy lifting by providing the expertise, tools, and resources.

If your pharmacy consultant is only coming in to check for expired medications and to look at your refrigerator, you are missing out on the real reason to work with one. As I have mentioned in several other posts, your pharmacy consultant should be qualified and working with your facility to ensure you have all these processes in place. Beyond that, they should meet with you regularly, in person or via video/conference call to provide you with clinical updates, regulatory updates, changes to the standards and best practices. After providing full assessments and all these updates, your pharmacy consultant should follow up with a comprehensive report which covers all these items and includes broad benchmarking studies. Smaller companies and pharmacists who only moonlight as “consultants” will not be able to provide many of these services, but especially benchmarking, which is a requirement of the accrediting agencies.

Safe medication management requires expertise and the development and implementation of solid processes. This is a challenge every single facility must take on, but it’s not one you should take on alone. To ensure patient safety and a smoother path through your next survey, start working today to develop or enhance your processes. If you’re not working with an expert pharmacy consultant, start now. If you have questions or need someone to point you in the right direction, give us a call.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.