JCAHO takes close look at medication safety systems
Surveyors looked for standardization of processes
During a recent JCAHO survey at Texas Tech University Health Sciences Center, surveyors looked for standardization of processes across the system’s 11 departments and 27 clinic sites, reports Becky Jones, RN, BSN, CPHQ, director of performance improvement.
"Since we are completely ambulatory care, there are some issues particular to our area. One of those involves maintaining medications," she says.
JCAHO’s standard requires you to have a system to track medications that are recalled. "If you gave out a sample of that medication, you need to have a way to track the patient and the lot number. Also, you need to document that instructions were given to the patient," says Jones.
A copy of the instructions is placed in the patient’s chart, and a running inventory kept on file with the patient name, medical record number, and lot numbers. However, the system is only successful with sample medications if there is controlled access, says Jones, noting that there are limited staff members with keys.
In the outpatient psychiatric clinic, surveyors noted that a full set of vital signs wasn’t always done, but the JCAHO standard says only that you must define your scope of assessment, notes Jones. "The surveyor asked for the policy and when it did not define a full set of vital signs, then we were fine," she says. "If you make your policies more stringent on yourself, then they will hold you to your policy."
In the point-of-care testing area, surveyors looked at quality control and wanted to see that certificates were up to date. "There must be two controls run, there should be quality control logs, and staff must be appropriately trained within the scope of the tests that were run," says Jones. "Surveyors will look at that, if it comes up in the course of a tracer."
The organization has a point-of-care testing manual that defines the scope of training required for staff, adds Jones. "For the summary list, they expect to see a list of chronic problems, surgeries, medications, and allergies," she says. "We have really struggled with that over time, and we continue to look at that."
A performance improvement team comprised mainly of nurse managers worked with department faculty to redesign the summary list. "It took some time to work this back and forth between family and internal medicine, but all the faculty came to a consensus about what they thought was meaningful and helpful on the form," says Jones.
Next, the team worked with pediatrics and family medicine to design a pediatric-specific summary list, since the adult one wasn’t appropriate to this patient population. The pediatric form added a place to track acute recurring conditions such as otitis media and strep, says Jones.
"That has helped a great deal, and we continue to emphasize the education and audit it to determine if the list is completed," she says. "We are doing better, but I don’t think it will be completely solved until we have an EMR within the next year."
At one clinic which already has an EMR, the surveyor zeroed in on security concerns. "They asked who had access to passwords and who could access what information, and asked about safeguards in place," says Jones. "We told the surveyor that the IT person is notified when someone leaves and passwords change every 90 days."
If you perform high-risk procedures in the ambulatory area, you need to be sure that there is an immediate procedure note in the chart, says Jones. "In one area, our physicians were dictating the note with a turnaround of 24 to 48 hours."
Physicians still can dictate the full note, but a procedure note with vital signs, pain assessment, and time-out verification is needed in the chart immediately. "Organizations need to think about adding a brief procedure note that shows what was done and what meds were given, basic assessment, and vital signs," says Jones.
During a recent JCAHO survey at Texas Tech University Health Sciences Center, surveyors looked for standardization of processes across the systems 11 departments and 27 clinic sites, reports Becky Jones, RN, BSN, CPHQ, director of performance improvement.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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