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Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2012 Update Webinar


Jaci wrote:

1) Should continuous narcotic infusions (eg, fentanyl, morphine) for pain be secured in lock boxes during administration?

2) Does TJC specifically require the words "beyond use date" on CSPs? The verbiage has generated confusion and we are wondering if "hang by" could be substituted if defined in policy as "beyond use date".


ANSWER: 1) We have no specific requirement that continuous narcotic infusions be secured in locked boxes during administration, unless the state laws require it,  Such boxes are relatively new and are considered better at ensuring loss prevention of controlled substances so organizations are using them, and could be considered a best practice but it not a requirement.  

2) We require no specific language - just the date.  "Use by", "Expires by", "Expiration date", "Hang By" are all acceptable or any other verbage that indicates it is the last date that the product is to be used by. 

Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2012 Update Webinar


John_Culp wrote:

This question has been asked and answered in another presentation, but would like to follow up : is it an acceptable practice as a substitute for labeling a syringe to tape the vial to the syringe? You had answered yes (with conditions), but this was challenged by a TJC consultant of ours who specifically asked this of the TJC SIG Group, who replied it was not.  Is there some documentation or statement to allow this practice, or do we need to apply for an exception?  Given that the traditional syringe labeling process does not account for a product barcode, we feel this is important to pursue.


Answer: No, it is not acceptable to tape a vial to a syringe and consider it a label.  I cannot image that I would have said differently - are you sure you didn't hear it elsewhere?.  We actually had a FAQ for the NPSG 03.04.01 that specifically stated this was not acceptable.  However, what I may have said is that attaching a vial to a syringe could be done in ADDITION to labeling the syringe but certainly not as a replacement. Since the Joint Commission already reviewed this issue and said no, I cannot imagine you will get an exception to the requirement, but you can try.

Occasional Visitor
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Registered: ‎11-16-2011
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Re: Joint Commission 2012 Update Webinar

Can a malignant hyperthermia kit be stored in a birthing center c-section OR room if the area is only accessable via a push lock? Within the c-section OR room, the kit (containing multiple medications), is not secure. The only security is the push locks. If you dont know the combination, you have no access to the hyperthermia kit. Should the kit be secured within the secure C-section OR room? Thanks

Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2012 Update Webinar


rxdave9 wrote:

Can a malignant hyperthermia kit be stored in a birthing center c-section OR room if the area is only accessable via a push lock? Within the c-section OR room, the kit (containing multiple medications), is not secure. The only security is the push locks. If you dont know the combination, you have no access to the hyperthermia kit. Should the kit be secured within the secure C-section OR room? Thanks


ANSWER: Push button locks are adequate security - you do not need to secure any further, unless you have security incidents.  You need to change the passcode on a regular basis, however.

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Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission 2012 Update Webinar

IMPORTANT---This is to let everyone know that I am no longer checking this forum to respond to questions. If you have any questions regarding Joint Commission standards, please call the Standards Interpretation Unit at 630-792-5900 or submit the question by using the following on-line form: http://www.jointcommission.org/Standards/OnlineQuestionForm.  Thanks.  Darryl S. Rich.