By Patricia Hane, RPh, Associate Director of Pharmacy Operations, SBH
Medication management is a cornerstone of patient care for many diseases and conditions.
Appropriate and safe medication use offers patients effective treatments that range from symptomatic relief, to palliative care, to actual cure. However, medication use also carries the risk of patient harm if an incorrect medication or dose is inadvertently administered.
Medication errors are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. The Joint Commission (TJC) has established standards for safe medication management systems to be used throughout hospitals in order to ensure patient safety is maintained and monitored. Medication management standards fall under the leadership of the Pharmacy Department. Medication management systems include many processes, including planning, selection, procurement, storage and ordering of medications, as well as preparation, dispensing, administration, monitoring, and evaluation of medication use.
The Medication Safety Committee is co-chaired by Pharmacy and Nursing Education and meets monthly to review all medication-related events, including actual or potential adverse events, significant adverse drug reactions, and medication errors. Quality, Medicine, Nursing, and Information Technology all play vital roles in analyzing medication events and designing solutions to improve and track medication management processes. Medication events are reported and tracked through Datix. All medication events are categorized by severity, according to the National Coordinating Council for Medication Error Reporting and Prevention Index.
TJC requires hospitals to follow a process to respond to medication events, including notifying the prescriber, investigating the root cause, and complying with all internal and external reporting requirements.
The Medication Safety Committee also manages several important medication lists, including high-alert medications, hazardous medications, and look-alike/sound-alike medications. The Institute for Safe Medication Practices (ISMP) publishes recommended high-alert lists. This list includes those medications on formulary that bear a heightened risk of causing significant patient harm or sentinel events, such as opioids, insulin, anticoagulants, and neuromuscular blocking agents. The Medication Safety Committee reviews the SBH High Alert Medication List annually, making updates as necessary. Hazardous medications are those in which studies in animals or humans indicate that exposure to them has the potential for causing cancer, developmental or reproductive toxicity, genotoxicity, or organ damage.
Many antineoplastic medications are considered hazardous. The National Institute for Occupational Safety and Health (NIOSH) establishes this list. The Medication Safety Committee reviews the list of SBH hazardous medications every year and updates it according to the current standard. TJC standards also requires that SBH addresses the safe use of look alike/sound-alike medications. ISMP publishes a list of look-alike/sound-alike medication name pairs, which the Medication Safety Committee uses to develop the hospital’s own list based on SBH utilization patterns and internal data regarding medication errors that have been reported through Datix.
The Medication Safety meeting reviews and reports on knowledge-based medication administration (KBMA) statistics to support the TJC standards that ensure that medications are safely administered. Barcode administration has been shown to increase medication administration safety by ensuring patient identification and identifying incorrect medications and canceled or changed medication orders prior to an incorrect administration. Circumventing KBMA decreases patient safety at the point of care. Pharmacy, Nursing, and IT work together to ensure that medications scan properly at the point of care. Medication Safety also reviews proposed new medication protocols, changes to existing protocols, pharmacy interventions on medication orders, and medication shortages.
The Medication Safety Committee reports to the Pharmacy and Therapeutics (P&T) Committee. All updates to policies and procedures and medication protocols are presented at P&T for approval. P&T is led by medicine and pharmacy, and is composed of members of the medical staff, licensed independent practitioners, pharmacists, nurses and staff involved in ordering, dispensing, administering, and/or monitoring the effects of medications. P&T determines which medications are included in the SBH formulary. This is accomplished by developing criteria for each medication, which includes indications for use, effectiveness, drug interactions, potential for errors and abuse, adverse drug events, sentinel event advisories, and populations served, as well as costs. Formulary management is vital to patient care and safety and requires constant oversight to manage medication shortages and outages as well as response to emerging safety data. Another medication safety group is the Opioid Stewardship Committee, which also reports to P&T. Opioid Stewardship ensures that opioids are used safely and effectively throughout the hospital, and tracks and trends opioid use throughout the institution.
TJC establishes standards for medication storage in order to maintain medication integrity and ensure the secure availability of medications at the point of care. Storage requirements for medications are based on manufacturer recommendations. Refrigerator temperatures are monitored to ensure safe storage at all times. Medication storage must also reduce the potential for diversion and reduce potential dispensing errors. Pyxis machines are automated dispensing machines that meet DEA and TJC standards for security of pharmaceuticals. Pyxis machines facilitate secure safe storage, and provide electronic record keeping for all dispensing, refills, returns, and wasting of medication. All medications in Pyxis must be labeled with medication name, lot number, and expiration date. Medication rooms are inspected monthly by pharmacy personnel to ensure that expired or damaged medications are removed and quarantined.
Emergency medications are chosen through P&T for use in Code Trays so that they are readily available to address patient emergencies. Code Tray medications are monitored by use of radio frequency identification (RFID) tags. Pharmacy personnel can monitor where all Code Trays for location are as well as lot and expiration data in the event of a recall. TJC requires that expired and recalled medications be trackable, with defined processes for quarantining these medications so they are not inadvertently reintroduced into the active pharmacy inventory.
Medication orders must be clear and accurate to support patient safety. TJC requires that that all as needed (PRN) orders are defined and are acted on based on a specific indication or symptom. For medication titration orders, required elements include the medication name, route of administration, initial rate of infusion, incremental units to which the rate or dose can be increased or decreased, how often the dose or rate may be adjusted, the maximum rate or dose, the objective clinical measure to be used to guide changes, and when to notify the prescriber.
Pharmacists must review the appropriateness of all medication orders. All medications orders are reviewed for patient allergies, interactions, and the appropriateness of the medication, dose, frequency, and route of administration, therapeutic duplications, and any contraindications that may exist. Pyxis machines on nursing units will not dispense medications until the pharmacist has reviewed and verified the medication order. Medication reconciliation is a National Patient Safety Goal and must be done by SBH providers whenever a patient moves from one level of care to another. TJC also requires that hospitals safely prepare and label all medications. The pharmacy compounds medications under the standards established by USP 795 (non-sterile compounding), USP 797 (sterile compounding) and USP 800 (hazardous compounding). Medication containers must be labeled whenever medications are prepared but not immediately administered. Labels include medication name, strength, amount, expiration date when not used within 24 hours, and expiration and time when expiration occurs in less than 24 hours.
In 2017, TJC established an antimicrobial stewardship standard to establish the reduction of inappropriate antimicrobial use in health care settings due to the problem of antimicrobial resistance. The Antimicrobial Stewardship Committee consists of an infectious disease physician, infection control specialist, pharmacists, and practitioners. This committee establishes guidelines for antimicrobial use, monitors antibiotic prescribing and resistance, and educates practitioners, staff, and patients on the antimicrobial program.
Effective and safe medication management involves multiple services and disciplines working together. Successful medication management supports patient safety and improves the quality of care by reducing errors and misuse, using evidence-based practices, and monitoring the medication management process for efficiency, quality and safety.