Changes in requirement for ED medication order review
Retrospective review by pharmacy now is allowed
During 2006 surveys, The Joint Commission found many EDs were not complying with Standard MM 4.10, which requires a pharmacist to review prescriptions or medication orders before these are given in the ED.
"The Joint Commission's position is that pharmacy review for all medication orders is important for quality and safety," says Robert Wise, MD, vice president of The Joint Commission's Division of Standards and Survey Methods. "What we've been hearing from EDs, though, is that prospective pharmacy review slows workflow, which can cause quality and safety issues."
The original standard said that an immediate pharmacy review was not required if the need for a medication is urgent and/or when a licensed independent practitioner controls the ordering, preparation, and administration of the medication. "What we found was that many EDs were calling any medication used in the ED as an urgent medication, which is clearly not true," he says.
As a result of these concerns, an interim action was approved specifically for EDs, allowing for the retrospective review of medication orders by a pharmacist in the ED, to be completed no more than 48 hours after the medication order was written or electronically recorded. The new requirement has the goal of preventing treatment delays and was effective as of Jan. 1, 2007.
The interim action permits medication orders to be reviewed retrospectively, but if a prospective system is in place and is working, the ED does not need to switch to a retrospective system, says Kelly Podgorny, RN, MS, CPHQ, project director in The Joint Commission's Division of Standards and Survey Methods. "The 48-hour requirement may be helpful to reduce patient backup in the ED, but each organization has to make that assessment for themselves," says Podgorny. "If a retrospective system is used, it should be done within 48 hours to make sure that any safety issues are dealt with."
Additional changes to the standard may be made in late 2007. "We are currently engaged in a field review for Standard MM 4.10 regarding other types of options that may be helpful to EDs," says Podgorny.
Many ED nurses report that they were unable to comply with the previous Joint Commission requirement. "It is a problem from a nursing perspective," says Debra Steveson, RN, clinical educator of the ED at Exempla Good Samaritan Medical Center in Lafayette, CO. There is a potential for delay of patient care, especially with patients reporting a high pain level, Steveson says. "The expectation of the public today is fast service," she says. "People are not willing to wait even if it means a safer delivery method."
Easier to comply
An ED information system could make it easier to meet the standard for many EDs, says Ellen DiStefano, RN, emergency services performance improvement manager at Providence Portland (OR) Medical Center.
During a Joint Commission survey last fall, surveyors looked closely at this area, reports DiStefano. "We did not have a system in place to review orders consistently," she says. However, when Providence Newberg (OR) Medical Center was surveyed the previous month, surveyors approved of the medication order review process, which used a newly implemented ED computerized information system (ED PulseCheck, manufactured by Wakefield, MA-based Picis) Pricing for the system, including standard interfaces, starts at $100,000.
The electronic system ensures that medication orders are consistently reviewed by the pharmacy. When a medication is ordered, a red "M" appears on the tracking board to notify the nurse that a order has been placed, says Julia S. Florea, RN, BSN, CCRN, CEN, emergency services manager.
"The pharmacy has access to our tracking board, and they watch for the red 'M,'" she says. "When they see it, they can go into the order and cosign the order if they agree with it."
The pharmacist also has the ability to see the patient's present medication list, allergies, and lab work if they think it is necessary, says Florea. "Because they have real-time viewing of the order, this allows them to cosign orders real time as well," she says.
Currently, 95% of orders are cosigned by pharmacy prior to the medication being given. "Even if we need to give a medication emergently, the pharmacist usually has cosigned prior to us getting into the room," says Florea. If not, one of the staff will call to let them know they need immediate review of an order. "Joint Commission loved our process and raved about how we were one of the few hospitals they had seen with this figured out," Florea says.
When the medication order is entered by the ED physician, it is displayed to the pharmacist electronically. The order is reviewed and acknowledged, and the nurse administers it. "We are considering using a similar process at our smaller EDs that do not have 24-hour pharmacists," says DiStefano. "The order could be entered and reviewed by a pharmacist at one of our larger facilities that staffs 24-hour pharmacists."
In contrast, faxing medication orders for review by the pharmacist is very inefficient, says DiStefano. "With the electronic system, we save five minutes per order," she estimates.
Sources/Resource
For more information on pharmacy review of ED medication orders, contact:
- Ellen Distefano, RN, Performance Improvement Manager, Emergency Services, Providence Portland Medical Center, 4805 N.E. Glisan St., Portland, OR 97213. Phone: (503) 513-1180. E-mail: [email protected].
- Julia S. Florea, RN, BSN, CCRN, CEN, Emergency Services Manager, Providence Newberg Medical Center, 1001 Providence Drive, Newberg, OR 97132. Phone: (503) 537-1782. Fax: (503) 537-1809. E-mail: [email protected].
- Debra Steveson, RN, Clinical Educator, Emergency Department, Exempla Good Samaritan Medical Center, 200 Exempla Circle, Lafayette, CO 80026. Phone: (303) 689-4605. E-mail: [email protected].
- ED PulseCheck is a web browser-based ED information system that combines triage, patient tracking, physician and nursing documentation, risk management, charge management, integrated voice recognition, and prescription writing. The cost varies depending upon the size of the installation and additional features. For more information, contact Picis, 100 Quannapowitt Parkway, Suite 405, Wakefield, MA 01880. Telephone: (781) 557-3000. E-mail: [email protected]. Web: www.picis.com.
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