Supporting The Joint Commission 2012 Standards and National Patient Safety Goals

Transcription

1 Supporting The Joint Commission 01 Standards and National Patient Safety Goals for Pyxis technologies This document highlights select Joint Commission 01 Standards and National Patient Safety Goals mapped to associated Pyxis technologies capabilities. It focuses on 01 Standards in the following chapters: Information management, Leadership, Medical staff, Performance improvement and Medication management. In addition, 01 goals referenced include: Improve the safety of using medications. Please consult for clarification of The Joint Commission 01 Standards and National Patient Safety Goals and their application to automated medication dispensing systems and additional products. This document is not all-inclusive. Information management IM Description Pyxis products Pyxis product capability The hospital protects the privacy of health information. The hospital monitors compliance with its policy on the privacy of health information. (See also RI , EP 7) IM The hospital maintains the security and integrity of health information. The hospital protects against unauthorized access, use and disclosure of health information. for Pyxis technologies Provides information and analytics on all user transactions on the Pyxis system. It helps to reduce unauthorized access to information on the Pyxis system and includes reports to monitor: Temporary Users, Repeat Temporary Users, # Active Users Without Activity in 90 Days and Users Without Biometrics (%). Helps to reduce unauthorized access to information on the Pyxis system and includes reports for: Temporary Users, Repeat Temporary Users, # Active Users Without Activity in 90 days and Users Without Biometrics (%). Pyxis

2 Leadership LD The hospital uses data and information to guide decisions and to understand variation in the of processes supporting safety and quality. 4 Leaders provide the resources needed for data and information use, including staff, equipment and information systems. The hospital uses data and information in decision making that supports the safety and quality of care, treatment and services. (See also NR , EPs 3 and 6; PI , EP 8) 6 The hospital uses data and information to identify and respond to internal and external changes in the environment. LD LD Data collection is performed on a nightly basis, with no additional technical staff or hardware resources required. The end result is delivery of actionable and concise information that may be shared or accessed by any designated users in the facility. Provides information for profile overrides (medication removal prior to pharmacist review) and potential diversion activities to support improvements in safety and quality of care. Key indicators (KPIs) track inventory levels so managers can modify par levels based on usage to prevent stock-outs and improve efficiency and productivity. The hospital communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families and external interested parties. Communication processes foster the safety of the patient and the quality of care. Communication is designed to meet the needs of internal and external users. Communication supports safety and quality throughout the hospital. (See also LD , EPs 6 and 1) When changes in the environment occur, the hospital communicates those changes effectively. Leaders evaluate the effectiveness of communication methods. Leaders implement changes in existing processes to improve the of the hospital. 4 Leaders provide the resources required for improvement and change management, including sufficient staff, access to information and training. Medical staff MS Selected KPIs (e.g., override %, stock-outs) can be tracked over time to evaluate effectiveness of communication strategies. Data collection is performed on a nightly basis, with no additional technical staff or hardware resources required. The end result is delivery of actionable and concise information, which may be shared or accessed by any designated users in the facility. The organized medical staff has a leadership role in organization improvement activities to improve quality of care, treatment and services and patient safety. 4 The medical staff is actively involved in the measurement, assessment and improvement of the following: Use of medications. (See also PI , EPs 1-4) Reports from these systems support the of medication usage evaluations and improvements in the medication use process.

3 Performance improvement PI The hospital collects data to monitor its. 14 The hospital collects data on the following: Significant medication errors. (See also LD , EP ; MM , EP 1) Reports of detailed transactions from Pyxis products can assist in analysis of medication errors. PI The hospital compiles and analyzes data. 3 The hospital uses statistical tools and techniques to analyze and display data. 4 The hospital analyzes and compares internal data over time to identify levels of, patterns, trends and variations. PI The hospital improves on an ongoing basis. 3 The hospital evaluates actions to confirm that they resulted in improvements. (See also MS , EPs 1-11) Medication management MM The hospital safely manages high-alert and hazardous medications. The hospital identifies, in writing, its high-alert and hazardous medications.* (See also EC , EP 8) * For a list of high-alert medications, see For a list of hazardous medications, see The hospital has a process for managing high-alert and hazardous medications. (See also EC , EP 8; MM , EP 9) The hospital implements its process for managing high-alert and hazardous medications. (See also EC , EPs 1 and 8) An online portal that provides trending, activity reviews, IDN summaries and KPIs, intra-idn benchmarking and costs that can help manage diversion, inventory management and compliance. The Executive Summary shows trends from the prior month and provides targeted and accurate information to base improvement initiatives, maximize staff productivity and inventory management of the Pyxis MedStation system. The monthly comparison contained in the Executive Summary indicates if the Plan-Do-Check-Act improvement interventions were successful. Monitor anomalous activity, which may indicate diversion or improper use of the Pyxis MedStation system. 3

4 Medication management (cont.) MM MM The hospital selects and procures medications. Members of the medical staff, licensed independent practitioners, pharmacists and staff involved in ordering, dispensing, administering and/or monitoring the effects of medications develop written criteria for determining which medications are available for dispensing or administering to patients. The hospital develops and approves criteria for selecting medications, which, at a minimum, include the following: Indications for use (see also MM , EP 10), effectiveness, drug interactions, potential for errors and abuse, adverse drug events, sentinel event advisories, other risks and costs. The hospital maintains a formulary, including medication strength and dosage. The hospital makes its formulary readily available to those involved in medication management. The hospital safely stores medications. The hospital has a written policy addressing the control of medication between receipt by an individual healthcare provider and administration of the medication, including safe storage, handling, security, disposition and return to storage. The hospital implements its policy addressing the control of medication between receipt by an individual healthcare provider and its administration. 6 The hospital prevents unauthorized individuals from obtaining medications in accordance with its policy and law and regulation. MM The hospital safely dispenses medications. The hospital dispenses medications and maintains records in accordance with law and regulation, licensure and professional standards of practice. Note: Dispensing practices and recordkeeping include anti-diversion strategies. 3 The hospital dispenses medications within time frames it defines to meet patient needs. Provides information on medication usage by generic name, user and station. Cost can also be added for inventory reports and patient transaction reports. Provides information on medication usage and cost. Monitor anomalous activity that may indicate diversion or improper use of the Pyxis MedStation system. Helps to reduce unauthorized access on the Pyxis MedStation 4000 system by providing reports for: Temporary Users, Repeat Temporary Users, # Active Users Without Activity in 90 Days and Users Without Biometrics (%). Provides information for profile overrides (medication removal prior to pharmacy review) and potential diversion activities to support follow-up and corrective actions. KPIs track inventory levels so managers can modify par levels based on usage to prevent stock-outs. 4

5 Medication management (cont.) MM The hospital safely obtains medications when the pharmacy is closed. When non-pharmacist healthcare professionals are allowed by law or regulation to obtain medications after the pharmacy is closed, the following occurs: Quality control procedures (such as an independent second check by another individual or a secondary verification built into the system such as bar coding) are in place to prevent medication retrieval errors. MM The hospital evaluates the effectiveness of its medication management system. 1 The hospital collects data on the of its medication management system. (See also PI , EPs 14 and 1) The hospital analyzes data on its medication management system. 3 The hospital compares data over time to identify risk points, levels of, patterns, trends and variations of its medication management system. 6 The hospital takes action on improvement opportunities identified as priorities for its medication management system. 7 The hospital evaluates its actions to confirm that they resulted in improvements for its medication management system. Profile Override (%) highlights medications accessed by users without a pharmacist s review. Data collection from the Pyxis MedStation system supports KPIs in four functional areas: inventory loss, inventory management, safety/compliance and system maintenance. The Cancelled Transactions (%) and Medication Usage reports are examples of data analysis designed to assist Pharmacy. Inventory Management reports provide detailed information on outdated medications and stock-outs to assist in managing labor and inventory. The Executive Summary shows trends from the prior month and provides targeted and accurate information to base improvement initiatives and maximize staff productivity and inventory management of the Pyxis MedStation system. The Executive Summary highlights potential compliance issues in controlled substance discrepancies unresolved within 4 hours, and number of controlled substance discrepancies that present opportunities for improvement and change implementation. The Number of Pockets without Removals for > 90 days and Average Removed Outdates per Station reports provide data to immediately initiate action plans to decrease medication costs that impact the operating budget. The monthly comparison contained in the Executive Summaries indicates if the Plan-Do-Check-Act improvement interventions were successful.

6 Supporting The Joint Commission 01 National Patient Safety Goals for Pyxis technologies Goal 3: Improve the safety of using medications NPSG Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. 8 Evaluate anticoagulation safety practices, take action to improve practices and measure the effectiveness of those actions in a time frame determined by the organization. Reports can track patients receiving anticoagulants as well as medications used to reverse the anticoagulant effects (e.g., Vit K, Protamine). 6

7 CareFusion San Diego, CA carefusion.com 01 CareFusion Corporation or one of its affiliates. All rights reserved. MedStation, Pyxis, CareFusion and the CareFusion logo are trademarks or registered trademarks of CareFusion Corporation or one of its affiliates. All other trademarks are property of their respective owners. DI34 (061/PDF)