In a presentation by Joint Commission Resources at ASHP Midyear 2021, Medication Storage and Security standards were among the top findings. From January 2020 to September 2021, up to 13% of hospitals had citations related to medication storage (MM.03.01.01 EP2), 12% with findings related to medication labeling (MM.03.01.01 EP7) and up to 10% with expired medications (MM.03.01.01 EP8). Here are the top ten things that might come up within a survey.
1. Storage per manufacturer
Are medications being refrigerated per manufacturers’ instructions? If so, is there a specific refrigerator dedicated to medications? They’ll also consider how medication storage conditions are being monitored—on what schedule, what details are being recorded, how and where details are documented. They may ask your staff about specific processes around temperature monitoring, especially on days when the unit is closed, and response to out-of-range temperature readings.
2. Medication security
Your surveyor will likely tour various nursing or procedural units to scan for medications stored in non-secure areas. They’ll look for a medication room with a properly locking door, the ability of non-authorized staff to access, and ensuring needles and syringes are secured from patients/public. They will also evaluate your overall compliance around controlled substance policies, including considering the audit process, wasting, discrepancy resolution and diversion auditing.
3. Medication handling after the pharmacy dispenses
Is there a policy describing the requirements for medication control from storage to administration to disposal? They’ll talk to your staff about their practices with wastage, and likely even want to observe the wastage process. They’ll also examine staff practices in returning medications to the automated dispensing cabinet, and their process for removing medications for multiple patients at once. Make sure practices match your policies!
4. Preventing unauthorized medication access
Your inspector will want to know if you have a policy that dictates authorized medication access. Are your staff trained about their access allowances and limitations? Do housekeepers in authorized areas know what to do if they interact with medication units? Make sure you can outline the process for assigning access to ADCs, as well as policy on temporary access.
5. Proper labelling
Medications should be labeled with the contents and expiration (or beyond-use) date unless the medication is prepared and immediately administered. The surveyor will check medication labels for expiration dates and auxiliary labels to ensure practice matches policy. Pay special attention to multi-dose vials, hazardous medications, and refrigerated medications.
6. Removal of medications
The surveyor will ask your clinical staff what they do when they find expired medications. Is it returned to the pharmacy, or discarded on unit? What is the disposal process, and is it consistent with hospital policy? Within the pharmacy, how are expired medications stored and marked? They’ll likely want to see a secured area for expired medications.
7. Concentrated electrolytes
Regarding concentrated electrolytes, such as potassium chloride or other potassium injectables, surveyors will want to see where they’re stored outside of the pharmacy, and if they’re stored in a way that provides adequate information about their use. Within operating rooms, they’ll check their accessibility as well as their monitoring process.
8. Inspection of medication storage areas
Across units outside the pharmacy, the inspector will want to know the frequency of required inspections for medication storage areas. They may select random units to request documentation from—having everything organized and prepared will streamline your process. Areas where inspections are often missed, such as nuclear medicine hot labs and radiology, might be of particular interest. Finally, you should be prepared to show how you document and mitigate inspection issues.
9. Patient’s own medications
If your organization allows patients to bring in their own medications, the surveyor will assess your policies to ensure all aspects of the medication use process are evaluated. For example, where are the patient’s own medications stored? Which department or role is responsible for evaluating the quality of the medication? Are patients allowed to administer their own medications? How is self-administration documented? How are patient medications returned to them or disposed of?
10. Sample medications
Your surveyor will want to know if your hospital policy allows the use of medication samples. If so, they will visit clinics to confirm whether the medication samples are used in accordance with policy.
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Mansur, J. and Janczak, D. Let’s Ask the Consultants: Joint Commission Medication Management Update 2022 – Strategies for Success. ASHP Midyear 2021.
Medication Management Made Easy. Joint Commission Resources 2021.