Pharmacist Review of Medication Orders

From the American College of Emergency Physicians (ACEP):

FAQs in Practice Management

Question: I have been told that JCAHO requires pharmacist review of medication orders prior to medication administration in the ED unless it is an emergency. Is this correct?

Answer: Yes. JCAHO standard MM.4.10 (Medication Management) states,

…a pharmacist reviews all prescription or medication orders unless a licensed independent practitioner (LIP) controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.

When queried by ACEP, the Joint Commission indicated that “the physician’s presence in the ED when medication is given is not viewed as control of the administration of medication.” Therefore any medication, including first dose, requires pharmacy oversight.

ACEP is currently working with JCAHO to resolve the problems that this standard is causing in many emergency departments.