Saturday, April 14, 2007

Joint Commission Changes Rx Review - Again

From ACEP:

Joint Commission Changes Rx Review - Again

The Joint Commission notified hospitals on April 9 that medications administered in an emergency department must once again be reviewed prospectively by a pharmacist. The action went into effect immediately.

The Joint Commission had issued an interim action on January 1 that allowed medications to be retrospectively reviewed by a pharmacist. This new announcement overturns that previous action.

The statement sent by the Joint Commission on April 9 follows:

Effective immediately!

The Interim Action for Standard MM.4.10 EP 1 for Emergency Departments has been suspended for an indefinite period of time. This Interim Action was implemented on January 1, 2007 for Emergency Departments in hospitals and critical access hospitals. With its suspension, MM.4.10 EP 1, as it is defined in your accreditation manuals, is back in effect for Emergency Departments.

Therefore in accordance with MM.4.10 EP 1 in the manuals, 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 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. Please remember that licensed independent practitioner control means that the licensed independent practitioner is physically present with the patient while the medication is being administered. With the suspension of the Interim Action, we are no longer requiring retrospective review for all medications in the ED that are not prospectively reviewed.

Please note, however, that Standard MM.4.10 EP 1 in the accreditation manuals is likely to be modified in the future as described in the January 2007 issue of Perspectives. The Joint Commission is currently developing revisions to MM.4.10 EP 1. Another field review will be forthcoming before the revisions are finalized, and it is anticipated that the revised standard/ EP will not be effective until 2008.

The reinterpretation of ' licensed independent practitioner control' for Radiology departments that are hospital based (including hospital-associated ambulatory radiology) remains in effect and is not impacted by the suspension of the Interim Action. You should continue to follow the defined aspects of THE reinterpretation: The organization is allowed to define, through protocol or policy, the role of the licensed independent practitioner in the direct supervision of a patient during and after IV contrast media is administered. The protocol/policy is to be approved by the medical staff and the role of the licensed independent practitioner is to be defined so that there can be timely intervention by the licensed independent practitioner in the event of patient emergency. The Joint Commission recommends that organizations refer to the American College of Radiology Practice Guidelines for the Use of Intravascular Contrast Media, 2001 during the development of the protocol/policy.

If you have questions, please contact the Standards Interpretation Group at 630-792-5900, Option 6 or through our online submission form at:


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