2017 Hospital Breakfast Briefings Medication Management

Transcription

1 2017 Hospital Breakfast Briefings Medication Management October 26, 2017 Don R. Janczak,Pharm.D.,M.S., BCPS, CPHQ Medication Management Consultant Joint Commission Resources

2 Disclosure Statement Disclosure Statement The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: Don Janczak Leslie LaBelle George Riccio Steve Chinn The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. 2 2

3 Publications and Record Restrictions The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. 3

4 Publications and Record Restrictions Copyright 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22 nd Street Suite 1300W, Oak Brook, Illinois

5 Focus List the top five most challenging medication management standards in 2016 Identify at least one strategy for compliance with the most common findings on survey for each of the above 5 standards Review the new and revised standards related to Pain Assessment and Management Understand The Joint Commission s Certification Program for Compounding Define the current Joint Commission accreditation standards that apply to sterile compounding 5

6 Self-Assessment Questions 1. The new and revised pain assessment management standards include all of the following requirements EXCEPT: a) Identifying a leader or leadership team that is responsible for pain management and safe opioid prescribing b) Involving patients in developing their treatment plans and setting realistic expectations and measurable goals c) Promoting safe opioid use by identifying high-risk patients d) Requires pain assessment for all patients with pain management being treated by an algorithm according to the patients pain score e) None of the above (i.e. All are standard requirements) 6

7 Self-Assessment Questions 2. Exemptions for the Pharmacist review of medications orders include: a) Oral contrast dispensed and administered for inpatients b) Urgent situations c) The presence of the LIP at the bedside d) All of the above e) B and C only 3. Which of the following is not an appropriate type of medication order? a. Standing orders b. Automatic stop orders c. Text message orders 7

8 Medication Management/NPSG Top Non-Compliant Standards 2016 Standard % Non-compliant MM Medication orders clear and accurate 35.18% MM The hospital safely stores medications 32.06% MM A pharmacist reviews the appropriateness of all medication orders for medications dispensed in the hospital % NPSG Labeling in OR/procedures 10.5% MM The hospital safely prepares medications. 6.66% MM Medication are labeled. 3.33% MM High alert /Hazardous Meds 3.26% MM The hospital safely manages emergency medications 3.05% 8

9 MM Medication Orders 35% 9

10 MM Medication Orders Clear and Accurate Medication orders are clear and accurate EP1: The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use PRN (indication/symptom), Standing orders, Auto Stops, Titration, Taper, Range, Compounded, med devices, investigational, herbal, order for medications at discharge or transfer EP 2: The hospital has a written policy that defines the following: The required elements of a complete order. Elements of complete order, when indication of use is required, precautions for ordering LASA meds, actions to take when incomplete, illegible or unclear. 10

11 MM Medication Orders Clear and Accurate Problematic EPs on Survey : EP 13: the hospital implements its policies for medication orders Failure to clarify unclear, illegible and incomplete orders Lack of indication on PRN orders Lack of special precautions for ordering LASA medications Titration orders without initial rate and parameters for titration Consistency in interpreting range orders 11

12 Titration Orders Expectations An order that provides guidance for administration and dose adjustments. Consistent Implementation 12

13 Titration Orders Expectations Policy must define required order components Medication name/ Route of administration Starting dose/ Maximum dose Incremental amount to either increase/decrease the infusion rate. Titration time frame (frequency) Assessment parameters Objective clinical endpoint Clinical endpoint must match what is being evaluated If clinical term such as adequate contractions is used then it should be defined in policy 13

14 Titration Orders Implementation Example of an acceptable order: Start nitroglycerin infusion at 5 mcg/min IV. Titrate by 5 mcg/min every 5 minutes to keep SBP less than 160 mmhg and greater than 110 mm Hg. Max dose 200mcg/min. Contact LIP if unable to titrate, SBP 90 mmhg, or continued chest pain or EKG changes. Problem-prone orders Start Norepinephrine infusion titrate to a MAP >65 Other Considerations Titration parameters in the order and not in a policy or guideline for reference 14

15 Range orders Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or patient s status MM EP 1 The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use 15

16 Range Orders Tylenol mg po q 2-4 hours PRN for headache, fever, or pain. Don't bother me orders The nurse is left to decide how much, how often, and for what reason. Morphine 2-4 mg IV every 3-4 hours prn for pain Is written without a policy in place for guidance, this leaves the criteria for medication administration up to nursing judgment, Is the RN considered practicing outside of her scope practice? 16

17 Joint Commission Standards on Protocols, Standing Orders and Order Sets for Medications What Hospitals Need to Know 17

18 What is the Difference? An order set is a list of individually selectable interventions or orders that the practitioner may choose from AMI, CHF, Pneumonia, Total Knee Replacement A protocol requires the patient to meet certain clinical criteria, but there must be an order to initiate the protocol and a copy of the protocol in the medical record Heparin protocol A standing order is an order that may be initiated without an initial order by the physicians or LIP by the nurse if the patient meets certain criteria. -ACLS, RRT, IV Start preop. Problematic Areas Radiology IV contrast protocols ICU hypoglycemia protocol, sliding scale, anticoagulation 18 18

19 Texting Orders 2011 TJC FAQ Not acceptable for LIPs to text orders for patient care, treatment, or services to the hospital or other health care settings. May 2016 Perspectives May allow text messaging with a secure text platform as long as system met specific requirements and all the requirements of the order are included. MM required elements of a complete order and actions to take when orders are incomplete or unclear Post May 2016 Perspectives Concerns remain even with a secure text messaging system. 19

20 Current TJC Recommendations Use of Secure Text Messaging for Patient Care Orders is NOT Acceptable All HCO should have policies prohibiting the use on unsecured text messaging from a personal mobile device for communicating protected health information. (IM EP1) TJC and CMS agree the CPOE should be the preferred method for submitting orders. In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable. The use of secure text orders is not permitted at this time Perspectives - December

21 MM Medication Storage and Security 32% U B Da Surveyor 21

22 MM Medication Storage and Security Problematic EPs: EP 3: all medications and biologicals are stored in secure areas to prevent diversion and locked when necessary, in accordance with law and regulation A secure area means that drugs and biologicals are stored in a manner to prevent unmonitored access by unauthorized individuals. EP 6: the hospital prevents unauthorized individuals from obtaining medications in accordance with law and regulation 22

23 MM Medication Storage and Security Key Points to Remember Areas secured if entry and exit are limited to appropriate staff, patients, visitors e.g. L&D, ICU, Psych, OR, Ped/Nursery These areas are secured ONLY if active and staffed OR suite when NOT in use is not secure. Lock the entire suite, lock non-mobile carts, place mobile carts in a locked room or lock drugs in a secure area. Mobile carts must be locked in a secure area when not in use. Carts are allowed in corridors Crash carts Isolation carts Chemo carts Computers on wheels? Rule of Thumb 30 minutes of inactivity Store when not in use 23

24 MM EP 7: All stored medications and the components used in their preparation are labeled with the contents, expiration date, and any applicable warnings. Findings on Survey Sterile MDV must use date of 28 days from the date of opening (see Perspectives June 2010) exceptions include: Vials where the manufacturer specifies a different beyond use date Vaccines whether VFC or purchased by the pharmacy the original manufacturer s expiration date is used per CDC When the original manufacturer s expiration date is less than 28 days from opening, the shorter date must be used If there are visible signs of contamination, the vial should be discarded immediately PPD and other biologicals are NOT vaccines and are not exempt. Original manufacturer s Allergen MDV used in allergy testing requires 28 days beyond use date once opened not exempt and are not considered vaccines. Unwrapped IV bags, chemical reagents, IV solutions, irrigations stored in warmers found without beyond use date 24

25 MM Pharmacist Review of Medication Order A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital Problematic EPs: 10.7% EP 1: pharmacist reviews all medication orders/prescriptions before dispensing/removing from floor stock or automated dispensing device 25

26 MM Pharmacist Review of Medications Exceptions for Pharmacist Review Urgency of situation or presence of LIP at bedside ED exception (LIP availability in the area to manage adverse drug event or urgent situations) Radiology Exception LIP direct supervision of a patient during and after IV contrast media, including timely intervention in event of a patient emergency Oral contrast dispensed and administered for inpatients Oral contrast in radiology per protocols does not require pharmacist review. 26

27 MM Pharmacist Review of Medication Order Findings on Survey : No pharmacist review when required Non-contrast medications in diagnostic areas for scheduled cases when no LIP at the patient bedside during administration of the drugs Cardiac stress: Dobutamine, Lexiscan, Adenosine Nuclear Med: Furosemide, etc Radiology: lorazepam, other meds given by the RN PACU non critical non-urgent care medications 27

28 MM EP 8 Pharmacist Review Therapeutic Duplication Problem Prone Orders: Morphine 2 mg IV every 10 min PRN pain Tylenol #3 1 tablet every 4 hours PRN pain Multiple medications for same indication must have guidelines as to which one to use and when Possible strategies to consider for compliance: 1. Stratify indications mild, moderate, severe pain 2. Take if po ineffective or NPO for parenteral/ suppositories 3. Prescriber may specify priority, sequence, and/or patient condition for use. 28

29 Auto-Verification: What is The Joint Commission Position? Auto-verification: A process that is part of the functionality of some EMR vendors that allows, depending on how it is set up by client, to allow access to medications without a pharmacist review Acceptable in ED How do you manage pharmacist review of orders with auto-verification in patients admitted still in ED awaiting a bed location? Is your EMR built with auto-verification in some settings where pharmacist review has been required? 29

30 MM Hospital Safely Dispenses Medications EP2 Hospital dispenses medications and maintain records according to law, regulation and standards of practice Findings on Survey Dispensing oral contrast by radiology to outpatients to take home. Dispensing practices not the same as the pharmacy Lacks proper labeling with patient name, directions, warnings.. ED Physicians dispensing medications for home use (ex. reconstituted oral antibiotic suspensions) Nursing providing patients supplies of inpatient meds for home use (ex. Insulin pens, multi-dose inhalers) 30

31 Automated Dispensing Cabinets Monitoring Overrides and Users How are you monitoring overrides? Presence of a medication order? Urgency of situation or presence of LIP at bedside? How do you manage users when employment is terminated? Internal transfers to other departments? Surveyors may review override med list and will ask for rationale of particular medications 31

32 Revision to Labeling Requirement NPSG EP3 10.5% In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the following: Medication or solution name Strength Amount of medication or solution containing medication (if not apparent from the container) Diluent name and volume (if not apparent from container) Expiration date when not used within 24 hours Expiration time when expiration is less than 24 hours Date and time not necessary for short procedures as defined by the hospital 32

33 NPSG Medication Labeling in Peri-operative and Procedure Areas See standard MM Medications are labeled Includes all medications and solutions Even if there is only one Even if it is obvious (Propofol is white, also lipids) Label must be applied immediately before or after filling container Also applies to anesthesia medications Applies to the O.R. and other procedural settings, not just invasive procedures Pre-labeled, empty syringes/containers are not acceptable 33

34 Propofol or EXPAREL? 34

35 NPSG Labeling Meds and Solutions Key Points to Consider: If you draw something up to use in a minute you label it! If you hold up a vial for a physician to draw out a med, he uses immediately you don t label it! If you inject part of a syringe into a port, and then remove the syringe for another potential dose for that same patient, you label it! Label each medication or solution as soon as it is prepared, unless it is immediately administered "Table It Label It" 35

36 MM The Hospital Safely Prepares Medications EP 1 6.6% Pharmacy compounds except in urgent situations in which the delay could harm the patient or short stability of the drug Issues on survey: Use of medications in procedural areas is not considered urgent if the case is scheduled in advance Meds not considered urgent if prepared and dispensed within the STAT dispensing time for the department. For example, if administered 1 hour after the order but only STAT IV order processed in 30 minutes then pharmacy prepares Short stability is not a reason for pharmacy not to mix if it is feasible to prepare, dispense, and administer within that time frame for dating No exceptions for LIP LIPs cannot make IV admixtures in lieu of pharmacy when above exceptions are not in effect 36

37 MM The Hospital Safely Prepares Medications Intravenous admixture Addition of a measured amount of drug to a 50 ml or greater bag or bottle of fluid given by any sterile route Mini-Bag Plus, Advantage, Add-a Vial systems, syringes and reconstitution of vials exempt EP 2 Staff use clean or sterile techniques and maintain clean, uncluttered, and functionally separate areas dedicated solely for IV product preparation. 37

38 MM The Hospital Safely Prepares Medications Issues on survey Outpatient clinics On site pharmacy prepares the chemotherapy but the premedications are prepared by the nurse OR, Procedure areas especially Cath Lab and IR Heparin infusions, irrigations, and other IV admixtures are made in these areas rather than by the pharmacy, often in nonstandardized concentrations 38

39 MM Safely Manage High Alert and Hazardous Medications Identify high-alert and hazardous medications High-alert meds are drugs that bear a heightened risk of causing significant harm when used in error the org defines the list of which drugs they will focus on for risk reduction strategies. How have you defined strategies for reducing risk? How have you disseminated information about risks and new processes? Hazardous medication any drug identified as hazardous or potentially hazardous by NIOSH (National Institute of Occupational Safety and Health) on the basis of at least one of the following six criteria carcinogenicity, teratogenicity or development toxicity, reproductive toxicity in humans, organ toxicity at low doses in humans or animals, genotoxicity, and new drugs that mimic hazardous drugs in structure or toxicity. Hazardous defined by NIOSH revised

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41 MM Safely Manage High Alert and Hazardous Medications Deemed status survey EP 5 Hospital reports abuses and losses of controlled substances In accordance with laws and regulations To individual responsible for pharmacy department To Chief Executive for the Hospital as appropriate 41

42 High Risk Practices 42

43 MM Safely Manage Emergency Medications Findings on Survey EP 2 Readily accessible Crash cart meds and/or supplies are out of date. Pediatric and adult medications in combined carts are not separated. EP 3 Unit dose, age specific, ready to administer Crash carts stocked as amps/vials when available from the manufacturer as prefilled syringes or premixed bags EP6 Resupply after use as soon as possible. Crash carts are sent to be replaced without a replacement cart arriving first, or the medication tray is removed without being immediately replaced and no other crash cart in the immediate area. 43

44 Readiness for Malignant Hyperthermia (MH) CoP Emergency Services The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice CMS requires: Access to MH carts/meds Staff training of early S/S and interventions Mock drills including obtaining the cart Evaluation of the drills and continued improvement CMS encourages staff training in all procedural and recovery areas, ER, OR, outpatient (anesthesia). 44

45 Malignant Hyperthermia Malignant Hyperthermia Association of the United States Dantrium /Revonto stock minimum of mg vials Ryanodex stock minimum of mg vials Available within 10 minutes of MH diagnosis (per MHAUS) Findings on Survey Areas of focus : all procedural and recovery areas, emergency rooms, OR, outpatient (anesthesia) Staff were unable to articulate where the malignant hyperthermia cart containing dantrolene was stored and where additional vials of dantrolene or Ryanodex could be obtained. Lack of staff training, drills,and evaluation of drills for continued improvement. 45

46 Look Alike Sound Alike Drugs 46

47 MM Safe Use of Look Alike/Sound Alike Medications Develop a list of LASA (one source is ISMP) Take action to prevent errors in interchange Hospital annually reviews and revises the list Written policy on the precautions for ordering medications with look alike or sound alike names (MM ) Examples of problematic names: CATAPRES (clonidine) and KLONOPIN (clonazepam) CELEBREX (celecoxib) CEREBYX (fosphenytoin) CELEXA (citalopram) Pharma Responsibilities? Losec 20 mg po daily. 47

48 MM Safe Use of Look Alike/Sound Alike Medications Two general areas of risk Pulling the med Ordering the med Strategies to Prevent Errors Consider multiple concentrations of the same medication. Defined policy precautions on ordering LASAs? Avoid abbreviations of drug names Physically separate agents in storage areas and automated dispensing cabinets Print generic and brand names on unit dose packages Use Tall Man lettering. Include prompts for nurse to specify indication for use when medication is removed from ADC hydralazine hydroxyzine Look Alike, Sound Alike auxiliary alerts on med storage bins 48

49 New and Revised Standards 49

50 The Joint Commission Medication Compounding Certification 50

51 Update on USP <800> Revised Official Date: December 1, 2019 Both USP <797> (revised) and <800> are anticipated to become official on December 1,

52 Self-Assessment Tool for Hazardous Drugs 52

53 Improving Safe Handling Practices for Hazardous Drugs Toolkit 53

54 Changes to Standards Related to Pain Assessment and Treatment Effective January 1, 2018 Perspectives July 2017 Vol 37 No7 54

55 LD EPs 1-3 Pain assessment and pain management, including safe opioid prescribing, is identified as an organizational priority for the hospital. EP 1 The hospital has a leader or leadership team that is responsible for pain management and safe opioid prescribing and develops and monitors performance improvement activities. EP 2 The hospital provides non-pharmacologic pain treatment modalities EP 3 The hospital provides staff and licensed independent practitioners with educational resources and programs to improve pain assessment, pain management, and the safe use of opioid medications based on the identified needs of its patient population. 55

56 LD EP 4 The hospital provides information to staff and licensed independent practitioners on available services for consultation and referral of patients with complex management needs. EP 5 The hospital identifies opioid treatment programs that can be used for patient referrals EP 6 The hospital facilities practitioner and pharmacist access to the Prescription Drug Monitoring Program databases EP7 Hospital leadership works with its clinical staff to identify and acquire the equipment needed to monitor patients who are at high risk for adverse outcomes for opioid treatment 56

57 MS The management and coordination of each patient s care, treatment, and services is the responsibility of a practitioner with appropriate privileges. EP 2 The hospital educates all licensed independent practitioner on assessing and managing pain. 57

58 MS EP 18 EP 18 The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following: Participating in the establishment of protocols and quality metrics Reviewing performance improvement data 58

59 PC EP 1 Standard: The hospital assesses and manages the patient s pain and minimizes the risk associated with treatment EP1 The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient s condition. EP1 The hospital uses methods, has defined criteria to screen, assess, and reassess pain that are consistent with the patient's age, condition, and ability to understand 59

60 PC EP 2 EP 3 EP 2 The hospital reassesses and responds to the patient s pain, based on its reassessment criteria. screens patients for pain during emergency department visits and at the time of admission. 60

61 PC EP 3-4 EP 3 The hospital either treats the patient s pain or refers the patient for treatment NOTE: Treatment strategies for pain may include pharmacologic and nonpharmacologic nonpharmacologic, pharmacologic, or a combination of approaches EP 4 (D) The hospital develops a pain treatment plan based on evidence-based practices and the patient s clinical condition, past medical history,and pain management goals. 61

62 PC EP5 (D)The hospital involves patients in the pain management treatment planning process through the following: Developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain. Discussing objectives used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) Providing education on pain management treatment options, and safe use of opioid and non-opioid medications when prescribed. 62

63 PC EP 6-7 EP 6 The hospital monitors patients identified as being high risk for adverse outcomes related to opioid treatment EP 7 (D) The hospital reassesses and responds to the patients pain through the following: Evaluation and documentation of response(s) to pain interventions Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control ) Side effects of treatment Risk factors for adverse events caused by the treatment 63

64 PC EP 8 (D) EP 8 (D) The hospital educates the patient and family on discharge plans related to pain management including the following: Pain management plan of care Side effects of pain management treatment Activities of daily living, including the home environment, that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues Safe use, storage, and disposal of opioids when prescribed. 64

65 PI EP 56 Standard: The hospital collects data to monitor its performance. EP 56 The hospital collects data on pain assessment and pain management including timing of reassessments, types of interventions, and effectiveness 65

66 PI Standard: The hospital compiles and analyzes data. EP 18 The hospital analyzes data collected on pain assessment and pain management to identify areas that need change to increase safety and quality for patients. EP 19 The hospital monitors the use of opioids to determine they are being used safely (for example, the tracking of adverse events such as respiratory depression, naloxone use, and the duration and dose of opioid prescriptions. 66

67 Pain Assessment and Management New Requirements 1. Identifying a leader or leadership team that is responsible for pain management and safe opioid prescribing. 2. Involving patients in developing their treatment plans and setting realistic expectations and measurable goals 3. Promoting safe opioid use by identifying high-risk patients. 4. Monitoring high-risk patients 5. Facilitating clinician access to prescription drug monitoring program databases 6. Conducting performance improvement activities focusing on pain assessment and management to increase safety and quality for patients. 67

68 What Surveyors Make Want To See on Survey? Some organization may have a pain team Right disciplines? Safe prescribing addressed at a higher level in the org Demonstrate that pain management is being addressed by leadership and medical staff Leadership monitoring PI activities Medical staff involvement in protocol development Non-pharmacologic Acupuncture Music 68

69 What Surveyors May Want to See on Survey? Policies, procedures, protocols Develop treatment plans (D) Could be evident in orders, physicians problem list Linked to nursing assessment and care plan Evaluation of risk factors related to opioid use What is your procedure for patients on PCAs? Required monitoring? capnography, pulse ox, more frequent monitoring per policy? At risk in compliance if practice deviates from protocol 69

70 What Surveyors May Want to See on Survey? Evidence based treatment plans (D) Up to the organization to define PI Process? Organization develops their own measures- to assess effectiveness. Possible indicators to Naloxone use Rate and duration of opioid use Compliance with protocols Education monitoring MUE post op surgical 70

71 What Surveyors May Want to See on Survey? Measurable patient goals linked with patient education For example documented in the patients notes:.i ve discussed with this patient available options for pain management.and the goal is to perform Activities of Daily Living with pain intensity of 2-3 Patient education handouts or provide other resources 71

72 MM Antimicrobial Stewardship EP 1 organizational priority EP 2. hospital educates staff and LIPs EP 3. educates patients and families EP 4 multidisciplinary team EP 5 core elements: Leadership commitment, Accountability, Drug expertise, Implementing recommended actions, Tracking, Reporting, Education EP 6 The ASP uses organization-approved multi-disciplinary protocols and policies and procedures. EP 7 The hospital collects, analyzes, and reports data on its antimicrobial stewardship program. EP 8 The hospital takes action on improvement opportunities identified in its antimicrobial stewardship program (Documentation Required ) 72

73 MM EP3: Effective EP3 hospital educates patients and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics. EP3 deleted based on feedback to TJC about the value of this education when the patients are too ill to receive and retain the information PC EP10 which requires patient education on the safe and effective use of medications based on the patients conditions and assessed needs, is still applicable when warranted Perspectives October

74 Revised MM EP s: Effective Jan 1, 2018 EC Hospital has a reliable emergency electrical power source EP 14 implement a policy to provide emergency backup for essential medication dispensing equipment.. EP 15 implement a policy to provide backup for essential refrigeration for medications by the critical access hospital Perspectives August

75 Revised MM EP s: Effective Jan 1, 2018 MM EP 4 The hospital has a written policy addressing the control of medications between receipt by the individual health care provider and administration of the medication, including safe storage, handling, wasting, security, disposition, and return to storage. MM EP1 The hospital has a written policy that identifies the specific type of medication orders.signed and held orders Perspectives August

76 Revised MM EP s: Effective Jan 1, 2018 MM Evaluate effectiveness of medication management system EP 16 When ADCs are used..a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews. Onehundred percent review of overrides is not required. RC The medical record contains EP2..any medications administered, including the strength, dose, route, date and time of administration. Perspectives August

77 Self-Assessment Questions 1. The new and revised pain assessment management standards include all of the following requirements EXCEPT: a) Identifying a leader or leadership team that is responsible for pain management and safe opioid prescribing b) Involving patients in developing their treatment plans and setting realistic expectations and measurable goals c) Promoting safe opioid use by identifying high-risk patients d) Requires pain assessment for all patients with pain management being treated by an algorithm according to the patients pain score e) None of the above (i.e. All are standard requirements) 77

78 Self-Assessment Questions 2. Exemptions for the Pharmacist review of medications orders include: a) Oral contrast dispensed and administered for inpatients b) Urgent situations c) The presence of the LIP at the bedside d) All of the above e) B and C only 3. Which of the following is not an appropriate type of medication order? a. Standing orders b. Automatic stop orders c. Text message orders 78

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80 Disclaimer These slides are current as of October 22, The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or Joint Commission Resources. 80