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Valued Contributor
Posts: 72
Registered: ‎02-22-2010

Post your experiences with the Joint Commission

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Occasional Advisor
Posts: 10
Registered: ‎04-26-2010

Re: The Joint Commission here now

The Joint Commission arrived here yesterday.  First few things we've heard about or have been asked about included IV/Chemo Room workflow,  gowning up, delivery mechanism of chemo meds to the unit they are administered at, and how long Baxter mini-bags are good for out of their outer-wrappers.   That answer is 15 days for bags 50ml or less, and 30 days for bags 100ml or more, per Baxter.   Also had an issue about a refrigerator  on a nursing unit, they thought it needed defrosting although the temp log reports show it to be working properly.   More another time.

Occasional Advisor
Posts: 10
Registered: ‎04-26-2010

Re: The Joint Commission was here - follow-up

    See the above comments I initially posted, we were actually "OK" in all of those practices, except of course we now know we (pharmacy) have to defrost/clean all the medication refrigerators/freezers, and not housekeeping.

    The Joint Commission ( TJC ) found several problems in our hospital's outlying clinics.  Inconsistancies in sample medication tracking (different clinics used different log-sheets and one was not nearly as thorough as far as data required) was one area we took a hit on. 

    The clinics that actually have a physician who dispenses also needed some kind of a mechanism by which drug lot# (and maybe Exp Dates) would be able to be tracked if a drug recall was issued.  The surveyer wanted a perpetual inventory on ALL drugs the clinic would dispense.  He was very surprised when i told him that in one of the retail stores I 'moon-light' at in town, they could not do a drug recall down to the lot# level, and that was not a requirement of the Board of Pharmacy.  We are awaiting the final written report to see where this issue goes.

   Also our physicians got a bit of a slap on the hand as they have been making the nurses cover for them in areas like renewing home meds and/or renewing pre-op meds.  The nurses have to fill-in the med-order forms and then (usually) cover it as a "verbal order" of the physician.  The surveyer wants the docs to fill out those forms themself, not have the nurse do it.

   Also the Ambulatory Surg. area nurses have been initiating 'standing orders' for proceedures like colonoscopys, which is what the docs want them to do, but the surveyer wants them to call the doc at like 5:45am asking them if they want to "use their standing orders".  The physicians do not like this suggestion....    This applies in other out-pt areas as well (Cath Lab, Radiology, etc) but for them it's a little less invasive as by the time these proceedures are normally done, the physician(s) are most likely already in the hospital.

   THC Surveyer also went through our standing orders to see that (for example) meds for sedation told to what level of sedation a pt. was to be brought to/kept at.  Having an order like "Versed 0.5mg - 2mg for sedation prior to proceedure" does not cut it.  For specific questions please ask.