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Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission Safe Injection Practices Webinar

[ Edited ]

pharmacist wrote:

Can a nurse cut a tablet on the unit, prior to administration?  We started cutting tablets in the pharmacy dept and it is becoming difficult.  Would it be acceptable by TJC to have pharmacy cut only the high risk meds or the most frequently used one-half tablets? Thank you!


 Yes, nurses can cut tablet with an appropriate pill cutter on the floor.  We are concerned that pill cutters are cleaned between patient use and nurses know which pills can be cut and which cannot.

Advisor
Posts: 23
Registered: ‎04-28-2010
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Re: Joint Commission Safe Injection Practices Webinar

Would drawing up a single ingredient out of a mulit-dose vial, into individual dose syringes a "compounded product" then? and therefore subject to low risk B.U.D.? or can the syringes be dated 28 days, as would the open vial?
Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission Safe Injection Practices Webinar


mphelps wrote:
Would drawing up a single ingredient out of a mulit-dose vial, into individual dose syringes a "compounded product" then? and therefore subject to low risk B.U.D.? or can the syringes be dated 28 days, as would the open vial?

The 28 days is only for manufacturer's vials that are opened.  The syringes should use an appropriate B.U.D. (e.g. USP 797)

Advisor
Posts: 12
Registered: ‎09-02-2010
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Re: Joint Commission Safe Injection Practices Webinar

Hello,

 

This webinar was quite helpful for us.  Thanks you!

 

Per TJC guidelines, would it be OK for Rotaglide to be added to a diluent bag in a procedural area?  Given that the product is a surgical lubricant and not a medication, would it fall outside of admixing regulations?

 

 

Visitor
Posts: 2
Registered: ‎04-25-2011
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Re: Joint Commission Safe Injection Practices Webinar

Temp logs: If we have alarming, memory thermometers on our medication refrigerators is it necessary to have a manual temperature log?  Vaccines are to be checked twice a day according to CMS.  Would having an alarming, memory thermometer meet this requirement?  Am I still required to document this on paper? I only have a log if the temp is out of range.

Visitor
Posts: 2
Registered: ‎04-25-2011
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Re: Joint Commission Safe Injection Practices Webinar

On Discharge our doctors are in a habit of writing "continue home meds" and then the patient is given a list of meds to continue.  This is a discharge instruction (not an order for dispensing) for the patient.  We have tried for years to stop them from writing this.  We are not using it as an order (ie.blanket order).  Would this still be considered a blanket order on survey when we give the patient discharge instructions and med list?

Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission Safe Injection Practices Webinar


jab801 wrote:

Hello,

 

This webinar was quite helpful for us.  Thanks you!

 

Per TJC guidelines, would it be OK for Rotaglide to be added to a diluent bag in a procedural area?  Given that the product is a surgical lubricant and not a medication, would it fall outside of admixing regulations?

 

 


Sorry I can't answer this question. as I am not familiar with Rotoglide and not enough information is provided.  If the FDA has classified it as a medication or it meets our definition (as in the glossary of the CAMH) and it meet the definition of an IV admixture (also in the glossary), then the pharmacy must prepare it.

Expert
Posts: 78
Registered: ‎06-02-2010
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Re: Joint Commission Safe Injection Practices Webinar


spc25 wrote:

Temp logs: If we have alarming, memory thermometers on our medication refrigerators is it necessary to have a manual temperature log? 

 

Answer: No

 

 Vaccines are to be checked twice a day according to CMS.  Would having an alarming, memory thermometer meet this requirement? 

 

Answer: the thermometer must still be checked twice daily

 

 Am I still required to document this on paper? I only have a log if the temp is out of range.

 

Answer: The logs of when the temp is out of range is sufficient.


 

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

Re: Joint Commission Safe Injection Practices Webinar


spc25 wrote:

On Discharge our doctors are in a habit of writing "continue home meds" and then the patient is given a list of meds to continue.  This is a discharge instruction (not an order for dispensing) for the patient.  We have tried for years to stop them from writing this.  We are not using it as an order (ie.blanket order).  Would this still be considered a blanket order on survey when we give the patient discharge instructions and med list?


Sorry, we still consider it a blanket order, since they are "ordering" medications for the patient to be taken at discharge.  Orders are not just for dispensing.  If the physician filled out a medication reconciliation sheet that specified which medications to take at discharge, AND  the physician wrote a separate order "Continue home meds per reconciliation sheet" - we would not consider that a blanket order.  Without reference to another list of specific medications, the order is not acceptable.  You need to figure out how to get them out of this habit.