Joint Commission flip-flops on ED medication reviews

June 18, 2007

An interim action that the Joint Commission initially viewed as a relief to hospitals regarding the timeline for pharmacists' review of emergency department medication orders was suspended after 14 weeks because the accrediting organization realized it had instead created a huge burden.

Effective Jan. 1, 2007, the Joint Commission issued an interim action for Standard Medication Management (MM) 4.10, Element of Performance (EP) 1 for critical-access hospitals and hospitals. The interim action did not require a prospective review of medication orders in the emergency department (ED) if a pharmacist conducted a retrospective review of medication orders within 48 hours. However, on April 9, 2007, the Joint Commission notified hospitals that the interim action was suspended immediately and indefinitely-that medications administered in an emergency department must once again be reviewed prospectively by a pharmacist.

The interim action was issued following concerns from emergency departments regarding Standard MM 4.10, EP 1 in the "Medication Management" (MM) chapter. Organizations found themselves consistently out of compliance with the requirements for a pharmacist to review medication orders before dispensing and administering the medication in the ED due to factors such as urgent patient situations, time, work flow constraints, and manpower. "It is tough for any institution to add services to any emergency department as well as have [physical] space available," stated George Delgado Jr., Pharm.D., coordinator of emergency services and emergency medicine clinical pharmacy specialist at Detroit Receiving Hospital and University Health Center. Joint Commission thought the interim action would prevent delays while retaining an R.Ph.'s involvement through a retrospective review.

While the Joint Commission revises Standard MM 4.10, the process for surveying EP 1 will be modified in the ED. In its communication, Joint Commission informed the hospitals that surveyors expect to see EDs complying with EP 1 for Standard 4.10 of medication management. In accordance with Standard 4.10 EP 1, prior to dispensing, removal from floor stock, or removal from an automated storage and distribution device, a prospective pharmacy review is expected for all medication orders unless a licensed independent practitioner controls the medication ordering, preparation, and administration-or in urgent situations (including a sudden change in clinical status) when the resulting delay would harm the patient. Licensed independent practitioner control implies the practitioner's physical presence with the patient during medication administration.

Pharmacists at Memorial Hospital and Manor, Bainbridge, Ga., an 80-bed rural facility and the only hospital in the county, try to be as involved as possible in the emergency department, which is open 24 hours a day. "At our hospital, the physicians have become more involved. They check the medications for accuracy and are present when the medications are prepared and administered. This is the approach we are using, but we realize it will not work for everyone," said Ellen S. King, R.Ph., pharmacy director at Memorial Hospital and Manor.

The interim action has not affected all hospitals the same way. At Detroit's Receiving Hospital, with its 100-bed ED, the announcement of the interim action had a limited effect on the pharmacy department. "We have been providing 24/7 pharmacy services in the emergency department for many years. For busier emergency departments, a prospective review of the medication order would not necessarily slow the care that a patient receives; however, it does have the potential to decrease medication error rates in a busy environment," stated Delgado. When the workload builds up, another pharmacist in the hospital can assist from a remote terminal, added Delgado.

Joint Commission stated that it is developing revisions to EP 1 for MM 4.10 and will conduct a field review before finalizing those changes. Wise stated that hospitals will be allowed to "more liberally interpret" the two exceptions to EP 1 until the changes go into effect. According to Joint Commission, these changes will not take effect until 2008. Wise believes that pharmacists need to be involved in activities in the emergency departments, and Joint Commission has not backed away from bringing their expertise to the EDs.