Hospital Pharmacy Regulation Report

Transcription

1 Vol. 2 No. 6 June 2004 Hospital Pharmacy Regulation Report INSIDE Case study A patient at one hospital suffered a stroke after a communication breakdown. Read about the dangerous implications of blanket reinstatements on p. 4. Medication-ordering policy Avoid writing a blanket resume all medications order. Get tips on how to transfer and resume medication orders on p. 5. Error-reporting policy Are you struggling to get staff to report medication errors? Check out this sample nonpunitive reporting policy and procedure on pp Medicare update CMS is seeking proposals for the Voluntary Chronic Care Improvement Program. Read about the eligibility requirements on p. 10. Goals tracker Find out how the proposed changes to the JCAHO s National Patient Safety Goal #3 might affect you on p. 11. Check out the July HPRR to see one hospital s experience with implementing CPOE. FOR PERMISSION TO REPRODUCE PART OR ALL OF THIS NEWSLETTER FOR EXTERNAL DISTRIBUTION OR USE IN EDUCATIONAL PACKETS, PLEASE CONTACT THE COPYRIGHT CLEARANCE CENTER AT OR 978/ JCAHO standard of the month MM.3.20 Cover yourself: Don t let blanket orders harm patient safety Know your policies, improve communication Communication is critical when writing orders to reinstate a patient s medication. Make sure that your pharmacy staff know who to contact if they receive a vague reinstatement order. The JCAHO s medication standard MM.3.20 requires organizations to prohibit blanket reinstatement of orders, which could include the following: Resume all medications Continue home medications Obtain home medications Blanket orders are dangerous Upper Valley Medical Center in Troy, OH, saw an 80% drop in serious medication errors after pharmacy director Thomas Bigley, RPh, MS, began sending staff thank-you notes with an enclosed $2 coupon to the hospital cafeteria in 2000, he says. The incentives led to an increase in error reports from 15 per month to per month, Bigley says. The increased reporting allowed the hospital to look for potential system flaws that could cause the because physicians could forget to include previous medications that could be vital, or nurses and pharmacists may misinterpret the order. Case in point: Find out what happened when a patient went without a vital medication because of a blanket reinstatement order on p. 4. What can happen Caregivers often halt certain medications before a patient undergoes a procedure. For example, a physician could discontinue an antiarrythmic drug before a procedure, says Michael Hoying, RPh, MS, pharmacy director at > p. 2 Five tips to increase error reporting How your facility can benefit from a nonpunitive culture errors, such as a lack of information on the medication administration record that leads a nurse to misread a medication administration time. It was a nice touch to let them know this is what we need to do to improve safety, Bigley says. We got more and better information with this process. Creating a nonpunitive reporting environment will not only lead to increased error reporting, > p. 6

2 Blanket orders < p. 1 Standard MM.3.20 at a glance Staff clearly and accurately document medication orders. Requirements for MM.3.20 The hospital must have written policies that address 1. what is required in a complete medication order 2. when staff may use generic or brand names in an order 3. whether or when staff must write an indication for use 4. necessary precautions for ordering look-alike or sound-alike drugs 5. what to do when orders are incomplete or unclear 6. what the policies must outline and what should accompany any order it uses, including as needed orders; standing, hold, or resume orders; titrating and taper orders; range orders; compounded drug orders; medication-related device orders; investigational medication orders; and discharge orders 7. minimizing verbal and telephone orders 8. reviewing and update preprinted order sheets 9. noting that blanket reinstatements of previous medication orders are unacceptable 10. documenting requirements for weight-based dosing for pediatric patients Fairview and Lutheran hospitals in Cleveland. After the procedure, the physician may issue a blanket resume all medications order because he or she intends for the patient to begin retaking the antiarrythmic. But because the physician discontinued the order rather than holding it, the patient may not be told to take the antiarrythmic. This could harm the patient if the patient needs the drug. Tip: Have a policy in place that clearly defines how physicians should review and reinstate medication orders. Make sure that pharmacy staff understand the policy. Check out a sample medication ordering policy on p. 5. Call with questions Train pharmacy staff to automatically call the physician if they receive a vague order. Such phone calls lead to better communication among caregivers and can prevent potential errors from blanket orders. The physician is the only one who knows what he or she means, say Sarah Moake, RN, nurse manager of the medical-surgical unit at Henderson (TX) Memorial Hospital. Staff at Henderson Memorial had the two following concerns when the hospital initiated its policy against blanket orders two years ago: Calling a physician could take more time Physicians might take an abrupt tone with the pharmacist Tip: Have enough information about the patient s medications when you call a physician to clarify an order. For example, if a physician gives an order to continue home meds, find a list of the patient s home medications and have that present when you call to confirm the order, says Sandra Fly, RN, Henderson Memorial s director of performance improvement, Page HCPro, Inc.

3 quality, and JCAHO accreditation. It just comes down to being as professional as possible and having as much information as possible, Fly says. Tip: Write a clarification in the patient s chart when you receive an order interpretation from the physician. Use technology to help The computer system at Cleveland s Lutheran Hospital allows physicians to print order sheets for patients every time they transfer from one care level to another. Physicians look at the profile, which includes a list of active medications on the order sheet, and they can check off the drugs they want continued and look to see whether any prescriptions are missing, Hoying says. We ve given them a streamlined process so they can t say, Resume all meds, Hoying says. They can take three minutes to check everything. The process saves staff time because the system lists every drug for the patient and pharmacists do not have to call a physician to clarify a blanket reinstatement or resume order, Hoying says. Fly supports using computer technology to help streamline the process. If all physicians at the hospital used electronic medication administration records (emar), they would not have to write out individual medication orders, Fly says. They would be able to access the patient s record online to adjust the medication orders. Henderson Memorial is a 96-bed facility, so only nurses and some ancillary services use emar, Fly says. Getting everyone on emar could cost a hospital millions of dollars, she says. Get support from the top Henderson Memorial Hospital has come up against some resistance from physicians who are reluctant to change usually because they are accustomed to writing their orders out longhand, Fly says. Henderson Memorial had one physician who refused to adhere to the blanket-order prohibition, Fly says. The medical executive committee had to resolve the issue to get him to change his practices. Support is there from the top, Fly says of her hospital s leadership. It has to be, or change won t happen. We d just beat our heads against the wall. Tip: Get hospital leadership to understand the importance of prohibiting blanket orders. Henderson staff follow a chain of command when confronted with blanket orders, Fly says. The five steps include the following: 1. Call the physician to clarify and rewrite the order 2. Notify the nurse manager if the physician refuses 3. The nurse manager notifies the house supervisor 4. The medical director speaks with the physician 5. The case goes to the medical executive committee if the physician still refuses to comply As always, education is vital A policy prohibiting blanket orders will only work if you educate your staff and explain the reason behind the changes. Richard Fradette, RPh, JD, MPH, an attorney with Beliveau, Fradette, Doyle & Gallant, PA, in Manchester, NH, offers continuing education seminars to pharmacists. Fradette walks pharmacists through cases, explaining how he would present them in court. He has participants serve as witnesses and jurors, which helps them understand what could happen if they were involved in a malpractice case because of a medication error. Henderson Memorial provided inservices to staff when the blanket orders policy began. Staff also issued reminders in handouts, sticky notes in the medication records, and fliers in the break rooms. You can write policies all day long, Fly says, but you have to give some education because people don t know the changes and why they re doing it HCPro, Inc. Page 3

4 Case study Miscommunication leads to missed dose, patient injury Picture this: A 71-year-old woman with a history of heart trouble returns to the hospital one month after having a stroke, complaining of nausea, vomiting, and vertigo. The woman is taking Coumadin, an anticoagulant, and the medication is included in her admission orders. Her physician orders a colonoscopy to check for intestinal bleeding and writes a separate order to hold Coumadin. After the colonoscopy, the attending physician issues a resume all medications order. According to hospital policy, the pharmacy interprets the hold Coumadin order with no specified time period to hold it as an order to discontinue the medication. Result: The patient goes without Coumadin for six days and suffers another stroke. Blanket orders can cause physicians, pharmacists, and nurses to omit certain medications that may be vital to a patient s treatment. In the above scenario, a miscommunication among caregivers caused the patient to suffer another stroke that resulted in slurred speech and memory loss, says Richard Fradette, RPh, JD, MPH, a Manchester, NH based attorney with Beliveau, Fradette, Doyle & Gallant, PA, who represented the patient in a negligence claim against the hospital. It s an inappropriate order, Fradette says. It should be prohibited, and in most institutions, it is. Communication breakdown In this example, the hospital policy and a lack of communication contributed to the error, Fradette says. Pharmacy interpreted all hold orders without any specified time period as a discontinue order, according to hospital policy. did not consider Coumadin an active medication. The reinstatement failed to cover the Coumadin. The patient told the gastroenterologist who performed the colonoscopy that she did not want her Coumadin held because it would prevent future strokes. The gastroenterologist performed a diagnostic colonoscopy instead, which did not require her to stop taking the medication. The gastroenterologist entered in his record that the patient did not want her Coumadin held. The attending physician then gave a telephone order to give scheduled Coumadin tonight. But the pharmacy interpreted this to be a single dose only, not an order to resume the medication, Fradette says. Get on the same page Pharmacy and nursing staff need to call the physician to clarify the order, Fradette says. Take the time to carefully review the order and call the physician for more information, which could help prevent a serious medication error, he says. You have to say, Doctor, I don t understand this order. I need more information, Fradette says. Physicians also need to modify their behavior, Fradette says. Hospital leadership may want to consider fining physicians $50 $100, that they must pay personally, every time they write a prohibited order. The fine could pay for the safety committee to finance education seminars, he says. Questions? Comments? Ideas? Contact Editorial Assistant Matt Bashalany That policy exists to prevent medications from being distributed to patients when they should not be, Fradette says. But the vague hold order posed a problem because when the attending physician issued the resume all medications order, pharmacy Telephone: 781/ , Ext mbashalany@hcpro.com Page HCPro, Inc.

5 Sample medication-ordering policy Policy: Hospital will develop, adopt, and maintain policies and procedures that support prescribing and ordering of drugs which will ensure their safe, clear, and legal use. Procedures: Abbreviation: Medication orders shall contain only abbreviations approved by the medical staff. A list of these abbreviations will be made available. Definitions: When used with medication orders Hold means discontinue Stat means within 15 minutes Now means within one hour (Nurse should bring order to pharmacy for Stat and Now doses) Generic substitution: For drug entities for which there are multiple sources and when a competitive bid opportunity exists, the pharmacy department, in collaboration with the hospital s purchasing group, will determine the source of medications. The medical review committee may at its discretion determine the source for selected drugs and such information will be disclosed in the formulary. The physician may elect to not allow generic substitution by so stating in writing on the initial order. Metric: Medication orders shall be written in metric notation only and shall avoid the use of a leading decimal. PRN: Orders for as needed or PRN medications shall specify the indication(s) for use and be specific for dose and dosage frequency. Renewal: The use of the terms renew, repeat, and continue in reference to previous orders are not acceptable. Standard administration times: Unless otherwise specified, staff will administer doses at the designated times. Therapeutic substitution: With approval from the medical staff, drugs or products may be substituted for different drugs or products. Examples of some over-the-counter medications that will be substituted are enteral formulae, liquid antacids, and multivitamins. The medical review committee shall authorize such substitution and shall make the medical and nursing staff aware of it. Time/date: All medication orders shall include the time and date written. Transfer orders: All existing orders for patients shall be canceled when the patient is transferred to a higher or lower level of nursing care or to the operating room. The physician shall rewrite all patient orders within 12 hours of transfer. Verbal orders: Verbal (direct or telephone) orders are to be written immediately and signed with the name of the prescriber and the name of the transcriber. Verbal orders for drugs may be taken by an LVN, RN, or RPh, as well as an RT and LPT, within the scope of their practice. Verbal orders must be authenticated by the physician, podiatrist, or dentist as soon as possible as specified by the rules and regulations of medical staff. Source: Henderson Memorial Hospital in Henderson, TX. Reprinted with permission HCPro, Inc. Page 5

6 Five tips < p. 1 but it can also help you look for potential breakdowns in the medication process. This will help improve safety and show the JCAHO how you handle medication errors and quality improvement. Build trust and increase reporting 1. Fifteen years ago, The Cleveland Clinic maintained an error log book, says David Gragg, RPh, MBA, pharmacy operations manager and medication safety officer. One error report would earn a staff member a warning, two error reports would earn a write-up, and three error reports would warrant a suspension. That punitive culture prevents hospitals from getting a true sense of what their error rate is, says Diane Cousins, RPh, vice president of the Center for the Advancement of Patient Safety at the U.S. Pharmacopeia (USP). Creating a nonpunitive environment means administrators must make staff feel comfortable when reporting errors and realize that the reports could help improve systems and patient safety, she says. Illustration by David Harbaugh It s about trust, Cousins says. To gain that trust, it does require a system that has no holes in it from the top down through the organization. Now every time a staff member reports an error, Gragg will send a thank-you note with a coupon for a free meal at Pizza Hut. Before the incentive program began four years ago, Gragg would receive 30 error reports per month. That number jumped to 110 per month as the culture became less punitive. There s always been this feeling that if I report an error, then my name is attached to that report, Gragg says. To increase reporting, we had to remove the individual blame. Supervisors at Upper Valley Medical Center once kept tally sheets for each employee, Bigley says. When employees reached a certain number of errors, they could face punishment. I thought that was nonsensical, to report an error when you re held accountable on a performance evaluation when [the error] could be a system issue, Bigley says. Changes like this would have to be made organizationwide and come from the top. Bigley got support from the chief operating officer, chief medical officer, and human resources director to remove the punitive measures from hospital policies, he says. Check out Upper Valley Medical Center s sample policy and error-reporting process on p. 8. Tip: Participate in staff meetings to reinforce the nonpunitive reporting environment and explain the new policy to staff. Can someone give me a hand? Identify system weaknesses 2. The new culture makes staff more observant, and they look for potential system flaws, Bigley says. For example, one intensive care unit nurse noticed that when nurses gave paralyzing agents to patients on ventilators, the drugs did not have labels that Page HCPro, Inc.

7 alerted staff that they are high-alert and dangerous medications. No death or injury occurred because of a mix-up between paralyzing agents and other medications, but an observant nurse helped avert a potential problem. Tip: Encourage staff to look for potential error and risk points and reward them for improving patient safety. Anticipating errors and correcting the flaw ahead of time is important to improving healthcare, Cousins says. You want them to anticipate, Cousins says. One attribute of a high-reliability organization is to anticipate failure and prepare for it. That s how you can build the safest system. Define policy violations 3. A nonpunitive environment does not free staff from responsibility in all cases. For example, the case against Charles Cullen, a former nurse who pleaded guilty to killing 13 patients in New Jersey, would be exempt from any nonpunitive shield, Bigley says. Tip: Include a statement warning that the hospital will punish deliberate or malicious acts. 4. Build comfort through education Educate your staff about your error-reporting process. Teaching them how the process works will make them feel more at ease. For example, all new employees at The Cleveland Clinic watch a five-minute video explaining what a nonpunitive system is and how to file error reports, Gragg says. Employees who come from hospitals that punish errors can gain an understanding of how The Cleveland Clinic handles reporting. Manage your time 5. With the increased error reporting, ensure that you have the time to compile and review the reports. Both Bigley and Gragg are responsible for reviewing error reports and even with the increased reporting, they handle the task without adding more staff. With pharmacy, this is an important priority for us, Bigley says. The bottom line is we have not added manpower to our system. It s an important use of my time, and I don t consider it a burden at all. But don t be fooled. Although you may receive more error reports, the quality of care is not necessarily decreasing. We found that as we drill down errors, we found areas we could improve, Bigley says. The most satisfying thing to see is that with all of our efforts, the most significant errors have decreased in time. HPRR Subscriber Services Coupon Start my subscription to HPRR immediately. Options: No. of issues Cost Shipping Total Print 12 issues $299 (HPRRP) $18.00 Electronic 12 issues $299 (HPRRE) N/A Print & Electronic 12 issues of each $374 (HPRRPE) $18.00 Order online at and save 10% Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, IL, MA, MD, NJ, VA, VT, FL, CT, GA, IN, MI, NC, NY, OH, PA, SC, TX, WI. States that tax products only: AZ, TN. Please include $21.95 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Signature (Required for authorization) Card # (Your credit card bill will reflect a charge to HCPro, the publisher of HPRR.) Expires Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web: HCPro, Inc. Page 7

8 Sample medication error-reporting policy Purpose: To establish guidelines for documentation and follow-up of medication occurrences. Medication error definition: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including the following: Prescribing Order communications Product labeling, packaging, and nomenclature Compounding Dispensing 3. Distribution Administration Education Monitoring Use No error Error, no harm Error, harm Error, death Category A B C D E F G H I Definition Circumstances or events that have the capacity to cause error An error occurred but the medication did not reach the patient An error occurred that reached the patient but did not cause patient harm An error occurred that resulted in the need for increased patient monitoring but no patient harm An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm An error occurred that resulted in permanent patient harm An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac arrest) An error occurred that resulted in patient death Source: The National Coordinating Council for Medication Error Reporting and Prevention. Reprinted with permission. The definition of harm is death, or a temporary or permanent impairment of body functions/structure requiring intervention. Intervention may include monitoring the patient s condition, change in therapy, or active medical or surgical treatment. Page HCPro, Inc.

9 This index was adopted July 16, 1996, by the National Coordinating Council for Medication Error Reporting and Prevention. Completion of medication error report The medication error form is to be completed after any medication error occurrence. If an employee identifies that he or she has made an error, that employee will initiate a form and notification. If an employee discovers the medication error after the staff member involved in the occurrence has completed his or her shift, the employee that finds the error is to initiate the medication error report. Each medication error in which the physician s order has not been followed must be reported to the patient s attending physician. Documentation of notification must be entered on the medication error report with any comments. The completed medication error report is submitted to the department manager for analysis and follow up. The manager will forward the medication error report to the pharmacy director. The patient s medical record is to reflect actual medication received. [Hospital ] supports nonpunitive reporting of medication errors as long as they are reported within 48 hours of error. Medication error reports written more than 48 hours after the error or falsely reported incidents will be referred to the manager for possible disciplinary action. Note: The nonpunitive reporting policy does not protect the individual if the error is the result of an intentional, malicious act or if practice standards have not been followed. Review of medication errors Initial medication error trends will be reviewed by the medication error continuous quality improvement (CQI) committee, performance improvement (PI) department, pharmacy and therapeutics (P&T) committee, and other committees to improve quality of patient care. Data will be graphed to facilitate interpretation. Trended aggregate data will be reported quarterly for evaluation by the P&T and PI committees. Procedure 1. When a medication error occurs, a medication error report is completed and submitted to the departmental manager. 2. Medication error report is sent to the 3. pharmacy director. 3. Data is entered into MEDMARX software. 4. Medication error data is presented to the Medication Error CQI team for trending and prevention measures. 5. Any issues of major concern or need for concurrent intervention should be directed to nursing supervisor/administration. Additional information 1. Any employee observing or discovering the error may file a report. 2. Staff must contact the prescriber if the error is Category D or higher. For Category C and lower errors, the caregiver must use discretion in contacting the prescriber. 3. If the error is Category D or higher, the employee must immediately notify the departmental manager (or nursing supervisor if the departmental manager is not available). Category D and higher errors will be referred to the PI department to ensure appropriate risk management. Source: Upper Valley Medical Center, Troy, OH. Reprinted with permission HCPro, Inc. Page 9

10 Medicare update CMS seeks proposals for therapy management Specialty pharmacists should encourage group practice involvement Clinical pharmacists in specialized practices should encourage their groups to get involved in a threeyear Medicare therapy management pilot project. The Centers for Medicare & Medicaid Services (CMS) began seeking proposals April 23 for participation in the pilot Voluntary Chronic Care Improvement Program, which aims to help Medicare beneficiaries with multiple chronic illnesses including diabetes and congestive heart failure to manage their conditions. Pharmacists have the expertise and knowledge to help patients with multiple chronic illnesses manage their medications and get the most effective treatment, says Gary Stein, PhD, director of federal regulatory affairs for the American Society of Health-System Pharmacists. It s long overdue, Stein says. We have been trying to inform [CMS] for years about the importance of clinical pharmacists. Physicians and nurses just don t have the expertise in medication therapy management that pharmacists have. Program benefits The Voluntary Chronic Care Improvement Program will reach between 150,000 and 300,000 Medicare beneficiaries, according to CMS. The agency will select providers in 10 regions to test the program for three years. Chronic illnesses account for seven out of every 10 deaths and more than 60% of healthcare expenditures in the United States, according to the Centers for Disease Control and Prevention. Individual pharmacists will not be able to participate in the program, but pharmacists in group practices such as anticoagulation or asthma clinics should encourage their practices to get involved, he says. Those pharmacists would be able to help patients manage their medications and maximize their treatment benefits, Stein says. CMS has not said how it will reimburse pharmacists for their medication therapy management services, Stein says but pharmacists will use the money to compensate themselves for their time with patients. Once the pilot program concludes in three years, Stein says he believes more pharmacists will want to offer their services. After CMS sees the value of this program, I think more and more pharmacists will get involved, Stein says. It s extremely important to patients. For more information or to download a proposal, visit The application deadline is August 6. JUNE/JULY Audioconferences: Upcoming events 6/17/2004 Understanding the JCAHO s Priority Focus Areas 6/23/2004 Average Sales Price: The Impact of New Medicare Drug Reimbursement 6/25/2004 Universal Protocol for Preventing Wrong-site Surgery 7/19/2004 JCAHO Medication Standard MM.8.10 Call customer service at 800/ to register. Page HCPro, Inc.

11 New JCAHO IV goal could burden small pharmacies Premixed IVs can reduce staffing stress, help meet proposed goal Use commercially premixed IV fluids when possible and ensure that your pharmacy staff receive training on how to prepare IV drugs, otherwise a proposed JCAHO 2005 National Patient Safety Goal revision could place a strain on your staffing levels. Revisions to Goal #3 (posted at require you to restrict IV drug preparation to the pharmacy. The JCAHO suggests purchasing premixed fluids as an alternative. The JCAHO s board of commissioners typically votes on the proposed set of goals in July. The goals usually become effective January 1 of the following year. The goal revisions would probably affect smaller hospitals with fewer resources and without 24-hour pharmacy coverage, says James O Donnell, PharmD, MS, an associate professor of pharmacology at Rush University Medical Center in Chicago. The proposed goal will require pharmacies to evaluate their staff coverage and how they prepare IV solutions, as more staff time could be required. The revisions may also make treating intensive care unit patients difficult because they often need medications quickly and cannot wait for the pharmacy to prepare them. For acute care patients, [the goal] is overdue, O Donnell says. Use something that s commercially available and premixed. Look at trends to meet your needs Moving all IV preparation to the pharmacy can affect larger hospitals as well. Stanford University Medical Center in Stanford, CA, had nurses do some compounding on the floors, says Carolyn Ma, PharmD, a pharmacy consultant at the hospital. When the hospital moved all compounding to the pharmacy, IV preparation time increased from 20 minutes to 40 minutes, she says. However, turnaround time decreased once staff became accustomed to the increased workload, Ma says. Tip: Evaluate your peak hours and determine when you need to prepare the most IVs at once. This will help you plan for adequate staff levels. Reduce stress with premixed IVs Premixed IV solutions can help ease staff burdens, Ma says. Premixed solutions come in a bag and are ready to give to patients. Once staff became acclimated to the increased volume that came with preparing all IVs in the pharmacy, the hospital began to purchase fewer premixed solutions, Ma says. When your hands are tied and you can t hire anymore staff, but you have some leeway in the drug budget, that s the way to go, Ma says. As you incorporate changes, you can take some of that back and make your own IVs. Beware of premixed meds Your pharmacy will probably not be able to purchase all medications premixed, says clinical pharmacologist and toxicologist David Benjamin, PhD. When a drug is in a powder form with no liquid added it can remain stable longer than if a liquid were mixed with it. Extreme temperatures could spoil some drugs if they are mixed well before patients receive them, Benjamin says. The need to prepare certain drugs such as antibiotics including vancomycin could pose a problem to hospitals without 24-hour pharmacy coverage, Benjamin says. Tip: Have a pharmacist on call who can answer questions about preparing medications and come to the hospital in an emergency HCPro, Inc. Page 11

12 Quick tip: Get pharmacy involved when tackling the JCAHO s IC standards Make sure you have representation on your hospital s infection control (IC) committee. The JCAHO s revised IC standards emphasize a collaborative approach to prevention and control, so having pharmacy s concerns represented is more important than ever. The revised standards take effect January 1, 2005 (go to the standards Web page at Although the standards will not require you to have a formal interdisciplinary IC committee, a committee is one way to ensure that your hospital complies, says Tammy Lundstrom, MD, vice president and chief quality and safety officer at Detroit Medical Center. Having a standing committee makes [IC] a priority, Lundstrom says. If you have a scheduled meeting with a standard agenda, it s more likely that you ll stay on task. Hospital Pharmacy Regulation Report Editorial Advisory Board David Benjamin, PhD Clinical Pharmacologist/Taxicologist Chestnut Hill, MA Michael Hoying, RPh, MS Pharmacy Director Fairview and Lutheran Hospitals Cleveland, OH Robert Marder, MD Director Quality and Patient Safety The Greeley Company Marblehead, MA William Sarraille, Esq. Sidley Austin Brown & Wood LLP Washington, DC Donna Soflin, PharmD Director of Pharmacy Tri-County Hospital Lexington, NE Douglas Wong, PharmD Pharmacy Healthcare Solutions AmerisourceBergen Corporation Fort Washington, PA The IC committee at Detroit Medical Center includes pharmacy staff, nursing staff, operating room staff, risk managers, physician leaders, and administrators, Lundstrom says. Organizations can add other representatives depending on the services they provide. The committee liaison can be someone other than a department manager, Lundstrom says. It may be advantageous to have a frontline healthcare worker, to get their perspective, Lundstrom says. An interdisciplinary IC committee can help you draft new policies that comply with JCAHO standards and still allow departments to function efficiently without extra burden, Lundstrom says. The IC committee can draft a policy, and department leaders can then bring that policy back and discuss it with their staff to make any necessary changes. We want to hear from you... For news and story ideas: Contact Editorial Assistant Matt Bashalany Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA mbashalany@hcpro.com Fax: 781/ Publisher/Vice President: Suzanne Perney Executive Editor: Julia Fairclough Online resources: Web site: Access to past issues: Subscriber services and back issues: New subscriptions, renewals, changes of address, back issues, billing questions, or permission to reproduce any part of Hospital Pharmacy Regulation Report, please call customer service at 800/ Hospital Pharmacy Regulation Report is published monthly by HCPro, Inc., 200 Hoods Lane, P.O. Box 1168, Marblehead, MA Subscription rate: $299/year or $538/two years Copyright 2004 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc. or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of HPRR. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Page HCPro, Inc.