Showing results for 
Search instead for 
Do you mean 

Reply
Highlighted
Administrator
Posts: 578
Registered: ‎02-22-2010
0

Joint Commission Safe Injection Practices Webinar

[ Edited ]

Thanks for joining our presentation with Darryl Rich on "The Joint Commission and Safe Injection Practices."

 

View the on-demand recording.

As of April 27, we have closed the thread for posting questions. Hope you find Darryl's answers useful!

Established Member
Posts: 5
Registered: ‎04-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

Darryl,

 

With regard to contrast media administration - you noted that pharmacist review is not required of IV contrast media orders if there is a protocol-based process in place.  What is the requirement for oral contrast - e.g. barium?

 

Thanks,

 

Dan

 

 

Occasional Visitor
Posts: 1
Registered: ‎04-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

What documentation is acceptable to JCAHO for stability dating on opened vials? Will references such as Trissel's Handbook of Injectable Drugs or letters from manufacturers with stability studies be deemed compliant from an audit perspective?  Will  the only acceptable source be the package insert? 

Frequent Visitor
Posts: 1
Registered: ‎04-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

Great Webinar.  Our hospital provides regular, NPH and Humalog insulins to each patient as  single use, but the Lantus insulin is multipatient use. So as long as we have "do not use beyond mm/dd/yy on vial, this is acceptable? 

Occasional Visitor
Posts: 2
Registered: ‎04-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

We have recently opened a Urology Clinic and they urologists are used to having their staff mix BCG in their office to administer.  Is this something we should be mixing at the hospital and delivering to them?  They are mixing and instilling in the bladder.

Administrator
Posts: 578
Registered: ‎02-22-2010
0

Re: Joint Commission Safe Injection Practices Webinar

Here are some questions from our live presentation:

 

Q: Is there any requirement for pharmacy to purchase a manufacturer pre-mix product vs. having the pharmacy extemporaneously prepare that product in the pharmacy? For example: purchasing a dobutamine drip from the manufacturer or the pharmacy preparing the drip in the same concentration.

 

Q: IV bags are sometimes pre-spiked in OR areas.  Does TJC have an opinion on this practice?

 

Q: If sdv of Omnipaque is multi-dosed in operating room area, is that considered an aseptic area? The product is very expensive and pain management docs want to multi-dose and use on multiple patients.

 

Q: In compounding outside the pharmacy department,  you mention uncluttered, clean area for use in areas such as critical care/ER.  When is this considered acceptable?

 

Q: With regard to contrast media in radiology, you referred to a protocol based process is acceptable for injectable contrast.  What is the requirement for oral contrast (barium, etc.)?

 

Q: What about pediatric doses of medications that are under 50ml? Do they need to be prepared in the pharmacy?

 

Q: If the pharmacy prepares a compound for injection use in the OR, it shouldn't be used for multiple patients.  Instead of preparing an entire vial for each patient (i.e. 30ml vial of a compound where only 0.5-1ml is used for each patient), can the pharmacy draw up syringes for each patient?

Visitor
Posts: 1
Registered: ‎04-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

You had mentioned nursing having access to a clean and uncluttered space dedicated for IV prep.  Would activating an Addvantage vial be exempt from this requirement when the drug is used for a first dose when pharmcy is closed.

Frequent Visitor
Posts: 5
Registered: ‎01-20-2011
0

Re: Joint Commission Safe Injection Practices Webinar

We need some clarification on nurse preparation of medications on the nursing unit. 

 

Some pharmacists are under the impression that NO admixing should be done on the nursing units (for example, reconstituting an Ancef vial and drawing up a dose for IVP or reconstituting a Nexium and giving the drug IVP). They believe that every med must be made in the pharmacy IV room and should be sent to the nurse in a ready to administer manner.

 

Others are under the impression that compounding of the above examples are acceptable but making of drips in a non-emergency situation is not allowed.

 

We all agree that  nurses can prepare drips in an emergency situaton (code blue).

 

Please elaborate on what is acceptable to make on the unit by a nurse.  If nurses can prepare the above examples of meds, does the hospital need documentation of medication preparation training.

 

Thank you. 

Expert
Posts: 78
Registered: ‎06-02-2010
0

Re: Joint Commission Safe Injection Practices Webinar


DanR wrote:

With regard to contrast media administration - you noted that pharmacist review is not required of IV contrast media orders if there is a protocol-based process in place.  What is the requirement for oral contrast - e.g. barium?

 

A protocol-based approach, using a screening tool, can be used in place of pharmacist review, for any contrast media - oral, rectal, IV.  Thus, it can be used in place of pharmacist review for barium as well.

 


 

Expert
Posts: 78
Registered: ‎06-02-2010
0

Re: Joint Commission Safe Injection Practices Webinar


abirt wrote:

What documentation is acceptable to JCAHO for stability dating on opened vials? Will references such as Trissel's Handbook of Injectable Drugs or letters from manufacturers with stability studies be deemed compliant from an audit perspective?  Will  the only acceptable source be the package insert? 


We requires, as does CMS, that you follow manufacturer's recommendations for expiration dating of opened vials. In the absence of specific manufacturer's recommendations, you must use 28 days.  You cannot use other references, like Trissel's.   Stability data is not the concern here - infection prevention is,  Unless the manufacturer has tested the bacteriostatic effectiveness for more than the normally required 28 days, the effectiveness of the preservative it only known to be effective for 28 days.  Thus, you must use what the manufacturer says or 28 days (with the exceptions I noted in my presentation - e.g. vaccines).