I was wondering if Joint Commission has any specific requirements for the preparation of high-risk medications (ex. concentrated electrolytes, opiates, insulin etc.) Currently (except for chemo) all of our IVs are completely prepared by the technician and then signed off by the pharmacist. Do high risk meds need to be drawn up and inspected by the pharmacist prior to injecting into the bag? If so is there a reference that is available that confirms this? Thanks!
High risk medications require special attention by the pharmacist when compounding them; from the storage requirements to the careful checking of the finished product. I am not aware of any regulation that requires the pharmacist to verify the contents of the syringe immediately before injecting into diluents bag. Your policy and procedure manual should explain how your institution handles the high alert/high risk compounding. If you do not have one, then I strongly suggest your write one up. However, that being said, I suggest that you inquire with your board of pharmacy if they have addressed this issue in their regulations. Regardless, the pharmacist must ensure that the technician compounding the high risk medication made it correctly. Usually, this is done by the asking them to explain the preparation process in its entirety to the checking pharmacist. Oftentimes, at our institution, the pharmacist will compound the high risk medication themselves and, then, ask a fellow pharmacist to verify and check it.
TJC has a lot of suggestions when dealing with high risk/high alert meds, I would suggest that you visit the TJC website for further information. For example, TJC does suggest that you limit the amount of different concentrations of the same electrolytes inventoried in your institution. For example, having one or two concentrations of KCl only, Also, TJC suggest that it be separated from the regular inventory and flagged with a "high risk" label among other things.
I hope this helps!
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Carlos M Marin, RPh Lead Pharmacist/IV Room/Oncology Overlook Medical Center 99 Beauvoir Ave Summit, NJ 07901 MailBox #277 O: (908) 522-2294 F: (908) 908-522-2583 carlos.marin@atlantichealth.org
It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature. ~John Brown
I concur wholeheartedly with Occasional Advisor's response. Our procedure permits technicians to make just about all types of parenterals, high or normal risk. Occasionally we get into desensitizing series, TACE, intra-optic injections requiring serial dilutions and strict tracking of dilution volumes, times, etc where it may be simpler for the pharmacist to be the one to "just do it." However that is a lost opportunity to teach, keeping the techs from learning and expanding their own repertoire, and most importantly sends a message of a lack of confidence in them and their skills. . We'll discuss it with the tech, and if they exhibit uncertainty, we try to offer the option of us watch them step-by-step as they prepare the item, and assure its proper preparation.
The big catch to doing all of this is time, as it takes the pharmacist out of the work pool to concentrate on a single patient's single item, or series, and leaves more work for fewer pharmacists to do. An alternative is the train the trainer process, where the time described above is taken with a few techs, or a lead tech if you have one, and letting them do the same thing as we would do, step by step. A small 15-30 minute show-and-tell with a handout (with pictures!) is another good method. In any case the pharmacist holds the ultimate responsibility for the accuracy, propriety, and integrity of the product dispensed to the patient.
How good are your techs? Often, as good as you let them be, and promoting their skills, showing them the odd, the unusual, the tricky, as well as the high cost, high risk drugs and their often multiple uses, is good for everyone. They're more skilled, both of you are more confident, and more pharmacist time ultimately can be used more effectively. They're not dumb, or you would not have hired them. Ignorance is simply the lack of knowledge, an imminently fixable problem which when done well is ultimately better for all - staff and patients.
Don't forget those ever-important dollar savings when a highly competent technician can perform something leaving the pharmacist to be doing those things they should be doing, such as reconciliation, and all the other work that IS to be done by the one with the license.
I agree with you and would like to add that in preparing high risk medications it is imperative that the personnel compounding (technician or pharmacist) are very well trained before allowing them to compound high risk medications. In general, the person will need to demonstrate their knowledge in compounding low-medium risk medications and demonstrate, experientially, their abilities to follow USP<797> procedures while CSPs. Once they have demonstrated the knowledge in all aspects of USP<797>, then they should be considered for further training in high-risk medications. As you know, high-risk medications have different procedural nuances that have to be followed. With high-risk compounding, more testing of personnel and product is warranted and mandated.
If your facility compounds high risk medications and your policies permit technicians to compound them, then the question of training (technician and pharmacist) and testing them bi-annually must be performed and documented.
Having qualified technicians compound high risk medications relieves the pharmacist to perform other clinical duties. However, the ultimate responsibility for the accuracy, sterility and stability of the medications solely lies on the pharmacist. Having qualified and trained technicians will ease this burden.
I must add that a lot of facilities outsource high-risk compounds due to the sterility testing that is required. Obviously, by doing this, will free up time for the pharmacist.
Carlos M Marin, RPh Lead Pharmacist/IV Room/Oncology Overlook Medical Center 99 Beauvoir Ave Summit, NJ 07901 MailBox #277 O: (908) 522-2294 F: (908) 908-522-2583 carlos.marin@atlantichealth.org
It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature. ~John Brown
Dear cm, re your response & comments about high-risk CSP preparation:
I appreciate the expansion on my comments concerning low- and medium risk product preparation, and that both rigourous training, testing,and continuous documentation of these are necessary. I offer that they are necessary for all levels of products prepared.
We've addressed the odd product, usually needed NOW, eg. ophthalmic antibiotic injections, both intraocular and subconjunctival, by maintaining a record of these individual preparations in a "recipe" file that is reviewed for compatibility, correct final concentrations and doses, proper drug choices, arithmetic, delivery methods, and any other relevant information. Before being added to the file, it is generated by a pharmacist, reviewed and approved by both the Inpatient Pharmacy Manager and the Director of the Drug Information Service.
This has proven useful when a newer staff member encounters such a situation and is asked for the treatments, often by house officers with little familiarity with the products themselves. These events become learning moments for all, and if/when changes are made or added, the process described above is repeated.
We do our best to balance "First do no harm" with treating the patient quickly and effectively.
Thanks for your expansion on high-risk CSPs and the training, certification, and monitoring processes.
