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Administrator
Posts: 578
Registered: ‎02-22-2010
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Re: Joint Commission 2011 Update Webinar

Here are our final questions from the live presentation:

 

Q: Does a documented indication for a drug have to be “drug x for indication x”?

 

Q: How does Joint Commission view Propofol?  Is this considered a moderate sedation drug or MAC?

 

Q: How can we ensure compliance with the read back requirement for medication orders upon using CPOE medication prescribing? Sometimes the physician might not wait on the phone to give the pharmacist time to enter the clarification in the CPOE pharmacy application, and read back the change.

 

Q: Regarding MM05.01.01 and IV contrast orders.  Could you describe a protocol-based approach to these orders in lieu of pharmacist first review and LIP inspections?

 

Q: Previous guidance seemed to indicate it was acceptable for a crash cart could be in public corridor and not in direct observation if the cart had to go by nursing station to move on unit.  Is that still true, or is it now direct view?

 

Q: Relating to medication security, how does the Joint Commission feel about Materials Management or Sterile Processing Department transporting used/opened crash carts with medications in them?

 

Q: Regarding your suggestion for access to hospital's Intranet site (for booster pack etc.): pharmacy is informed that our intranet site is limited by TJC to a very small number of people. Can TJC increase the number of people who can have access to this site?

 

Q: Will JC be reviewing nursing administration times and citing those that fall out from the 30-minute prior or after admin time?

 

Q: Are Saline Flushes considered a medication that need to be listed on the MAR?          

Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2011 Update Webinar

[ Edited ]

 


HeatherQ wrote:     

 

Q: What expiration should we give On-Q pain pumps?  USP 797 states 48 hours for non-refrigerated medications if low risk.  Pain pumps can be used up to 3 days.

A: That is for you to decide.  TJC has no standards addressing this.

 

Q: Can you comment on whether you are citing nuclear medicine for radiopharmaceutical preparations with a BUD that are contrary to the manufacturer's package insert?

A: Yes, many of these products have a BUD of less than 23 days.  For example, Omnipaque has a BUD of 8 hours. We will cite any organization that is not following the BUD in the manufacturer’s package insert UNLESS they have a letter or other documentation from the manufacturer stating otherwise.  In addition, the 200ml and 500ml bottles of Omnipaque are listed in the package insert as a “Pharmacy Bulk Package”  – Not for Infusion Directly into Patients”.  The use of the products AT ALL in Radiology will result in a citation at MM.05.01.11 for not using the most ready-to-administer form of the drug (an FAQ will be posted regarding this on the TJC website in a month or two).  These products can only be used in the pharmacy in a laminar flow hood to make smaller dosages forms that are then sent to the radiology department. I cited a hospital this past week for doing so.  Finally, we expect the pharmacy to prepare all sterile compounded admixtures (MM.05.01.07, EP 1). If the radiology department is preparing IV admixtures, they will be cited.                        

 

Q: Concerning the CMS guideline to use single dose vials on multiple patients to minimize waste such as on chemo, how do your recommendations affect this JW modifier issue?

A: ??? I do not know what a JW modifier is. However, we require that the CDC (not CMS) Safe Injection Practices guidelines must be followed for single dose vials administered in the patient  care area (see question below).

 

Q: Regarding the CDC Safe Injection Practices, how does this apply to compounders where it is standard to use one bag for more than one patient?

A: These guidelines only apply in the patient care setting and not in the compounding (clean room) of the pharmacy.  Thus, one bag cannot be used for more than one patient in a procedural area (such as radiology) or cath lab.  However, it can be used within a laminar flow hood or other ISO 5 environment in the pharmacy for compounding purposes.

 

Q: Could you discuss an example of a warfarin guideline that you have seen that meets the JC standards?

A: Most follow the ACCP Guidelines Antithrombotic and Thrombolytic Therapy, 8th Ed: found in the journal, Chest.  Here is a link: http://www.chestjournal.org/content/vol133/6_suppl . The shorten these to a few pages, then have them approved by the Medical Staff thru the P&T Committee.  These are then posted or distributed for all physicians/prescribers to use.

 

Q: Do you have to have daily INR monitoring or only when you change the dose?

A: You must have a current INR documented in the medical record before the dose is dispensed/administered.  You need to determine in policy how current the INR must be – one week prior, etc.).

 


 

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Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2011 Update Webinar


HeatherQ wrote:

Here are our final questions from the live presentation:

 

Q: Does a documented indication for a drug have to be “drug x for indication x”?

A: No, but it must be clear from the chart that the drug is prescribed for the indication.  For example, a progress note that states that the patient has condition x, and then describes the treatment plan which includes drug x.

 

Q: How does Joint Commission view Propofol?  Is this considered a moderate sedation drug or MAC?

A:  We expect organizations to follow the requirements/recommendations in the manufacturer's package insert.  The package insert for propofol requires that the drug be treated as an agent for deep sedation and specifies appropriate monitoring parameters for the use of the medication - we expect these to be followed.

 

Q: How can we ensure compliance with the read back requirement for medication orders upon using CPOE medication prescribing? Sometimes the physician might not wait on the phone to give the pharmacist time to enter the clarification in the CPOE pharmacy application, and read back the change.

A: The pharmacist needs to write down the order on a piece of paper and read it back.  It can be entered into the computer program later.  The paper does not need to be saved.  Surveyors will evaluate the process, not the documentation.

 

Q: Regarding MM05.01.01 and IV contrast orders.  Could you describe a protocol-based approach to these orders in lieu of pharmacist first review and LIP inspections?

A: The most common approach is a screening form that the technologist uses to evaluate if the patient has diabetes, renal dysfunction, is receiving metformin and/or other drugs, had a previous reaction to contrast, etc.  If certain criteria on the form falls out of range, then the technologist needs to call the radiologist before proceeding with the administration of contrast.

 

Q: Previous guidance seemed to indicate it was acceptable for a crash cart could be in public corridor and not in direct observation if the cart had to go by nursing station to move on unit.  Is that still true, or is it now direct view?

A: All medications, including those on a crash cart, need to be under constant surveillance or in a locked room.

 

Q: Relating to medication security, how does the Joint Commission feel about Materials Management or Sterile Processing Department transporting used/opened crash carts with medications in them?

A: This acceptable as long as it is defined in policy.

 

Q: Regarding your suggestion for access to hospital's Intranet site (for booster pack etc.): pharmacy is informed that our intranet site is limited by TJC to a very small number of people. Can TJC increase the number of people who can have access to this site?

A: Contact the Joint Commission for this request.  However, your TJC coordiator can access the site and print out the boosterpak.

 

Q: Will JC be reviewing nursing administration times and citing those that fall out from the 30-minute prior or after admin time?

A: No, we know that this is controversial, so we are currently not reviewing this, but it is a CMS requirement..

 

Q: Are Saline Flushes considered a medication that need to be listed on the MAR?    

A: No, the FDA currently consideres these (as well as heparin flushes) as medical devices and not drugs. So we do not consider them medications.