Pharmacy experiences with JCAHO

From HMCwiki

Here are some excerpts related to pharmacy experiences with JCAHO from the JCAHO-sponsored conference " Unannounced Surveys for Hospitals Teleconference" on Thursday, March 9 2006. In it, JCAHO asked a small, medium, and large hospital that had the unannounced surveys to speak about their experiences and answer a few questions. The following has been directly copied from the transcript of that call, which can be downloaded in it's entirety here .

Q&A

QUESTION: What have your findings been regarding compliance with the National Patient Safety Goals in particular the do not use abbreviations and med reconciliations?
DR. JEFF SMITH: I would say those are two things that are very challenging, and are two things that actually which we were cited as a requirement for improvement despite extensive work over the past several years in this area. I don’t have a magic solution to it and I don’t think there is one. It’s a matter of ongoing education and monitoring and correction and feedback as it happens. But I would say despite our extensive efforts, it’s very difficult to comply with and it seems to be a challenge.
LINDA MURPHY-KNOLL: This is Linda Murphy-Knoll at the Joint Commission. I just wanted to let everyone know that we’re finding that about 44 percent of all organizations are cited for the do not use abbreviations National Patient Safety Goal.

QUESTION: How was medication reconciliation dealt with as one of the National Patient Safety Goals?
GLORIA SWANBON: They looked to see what our process was. They were pleased with our process. We had, as the other facilities have, spent a great deal of time on this process. We have changed our form and we have finally come up with one that actually works for us. We use a colored form. It is in the same place in all of the medical records. When you open a chart you can see it. It’s easy to find and they had commented on it. On how effective they felt it was. We did not get cited on it. We have been able to show improvement over the past year along this area and we’re not through. We continue to work with it but they looked at it and they were very objective looking at it and could see that we had worked at it and had made some progress and successes.
WANDA COOPER: That medication reconciliation was one of the issues that our surveyor was anxious to see when he watched the teaching of medications to the patient that was discharged. He listened very carefully for how our pharmacist addressed that with the patient, the meds that the patient already had at home.

QUESTION: What kind of documentation did the surveyors expect to see as evidence of medication reconciliation? Were they more interested in the process or in the documentation of the reconciliation?
WANDA COOPER: He seemed to be more interested in seeing the process as part of the tracer. You know, our pharmacist showed them instructional informational sheets that we give to our patients when they leave but it was actually the process that he was interested in seeing.
GLORIA SWANBON: They also were interested in the process as part of the tracers. They looked to see what happened on the transfer from one unit to another, you know, we have ICU, 17 we have patients coming in from the ED. They go to ICU, they go to med-surge [sic], they may go to TCU. Most of the tracers they did here were for patients that had gone to more than two units and so they looked to see that we were following through on the medications as well.
DR. JEFF SMITH: I would say one area that they looked at was when patients went for procedures and not just surgical procedures and their general anesthesia but when patients went for a cardiac catheterization or an endoscopy to the GI lab or to the pulmonary function lab for a bronoscopy [sic], those procedures typically don’t have lots of medication changes but at the same time they were expecting medication reconciliation to be done as the patient came back to the unit.

QUESTION: We just recently heard from another facility that surveyors are not looking into the unapproved abbreviations.
JOE CAPPIELLO: I would say that that’s absolutely incorrect. That is one of our National Patient Safety Goals. We have talked about this extensively on the side of patient safety and quality and I would expect that that would be looked at any time our Joint Commission staff is at your facility.

Related links

A small hospital's experiences with JCAHO
A medium hospital's experiences with JCAHO
A large hospital's experiences with JCAHO
Coping with JCAHO changes
JCAHO (definition)
JCAHO surveys by department
Pharmacy experiences with JCAHO
Preparing for an unannounced JCAHO survey
Preparing your staff for JCAHO
Unannounced Surveys for Hospitals Teleconference
Rehabilitation Services experiences with JCAHO
The morning of the survey

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