Changes to Medication-Related NPSGs for 2010

February 2010 - Vol.7 No. 2

While The Joint Commission’s (TJC) 2010 modifications to the national patient safety goals for hospitals were minimal in terms of new requirements, there are some important changes that need to be acknowledged. Of note, is the fact that we have yet to realize the proposed modifications to the medication reconciliation safety goal, and TJC has indicated they will continue the moratorium on scoring this safety goal throughout 2010. We do anticipate seeing a draft of the 2011 medication reconciliation requirements by the middle of 2010.

Goals Moved to Standards
In addition to changes to the safety goals, a number of goals were moved to standards this year. When a goal becomes a standard, it is important to remember that it has not been diminished; rather, it simply moved elsewhere within the standards manual. Standards, like goals, are score-able and will still lead to requirements for improvement (RFI). However, safety goals are always a focus of surveyor training, thus they are a priority consideration each year. There are approximately 300 standards and almost 2,000 elements of performance, which on a comparative basis receive much less focus than goals at surveyor training and on survey.

Verbal Order Read Back
This 2009 safety goal has moved to PC.02.01.03, EP 20 for 2010. In 2009 there were three elements of performance associated with this requirement. In 2010 there is only one, and it simply states that you must record and read back a verbal order. The term “record” is new, and effectively refers to the act of writing down or entering into a computer the verbal order. The move from goal to standard and the revised wording are not really significant. What remains a problem with this requirement is simply getting people to say it and do it as a write down and read back. Too often staff either verbalize a repeat back only, or are actually observed by the surveyor merely repeating back the telephone order, and then writing it down later.

Do Not Use (DNU) Abbreviations
This safety goal moved to IM.02.02.01, but is essentially unchanged for 2010. The minimum list of prohibited abbreviations remains the same (see Table 1). Bear in mind that if you exceed TJC’s minimum list, you must enforce your own policy, and TJC will score this standard if someone uses an abbreviation listed on your more extensive prohibited list. Also, remember that the prohibition on DNU abbreviations is not just for medication orders, but all medication-related documentation. Thus, when performing your internal preparation audits be sure to review progress notes and procedure logs for prohibited abbreviations.

There is one minor, yet notable effect of the change in the requirement: TJC will still count DNU abbreviations used on preprinted order forms against you, but apparently the fact that they were on a preprinted order sheet is no longer a prohibition on attempting a post-survey clarification. Given that the onsite surveyor technique for scoring this issue only requires two observations of non-compliance to get the RFI, it is increasingly important to try a post-survey clarification audit to demonstrate you are 90% or more compliant. The technique for this audit recommended by TJC is very difficult to fail. Be sure to read TJC’s Evidence of Standards Compliance (ESC) guidelines posted to your hospital’s secure site on T JC’s extranet, Joint Commission Connect. While counting each proper and improper use of abbreviations for the audit is a lot of work, it is worth the effort if it precludes the need to conduct post-survey measure-of-success audits for four successive months. Almost no hospital should be left with this RFI if you perform the clarification audit. Given that TJC reported 25% of hospitals received this RFI in the first half of 2009, clearly many hospitals are not aware of this audit technique.

Hand-off Communications
This requirement moved to PC.02.02.01, EP 2 for 2010. While there are many non-medication-related issues in this standard, TJC did add a requirement in 2009 that remains in 2010, which is to discuss medications during hand offs. Hand-off tools and techniques should discuss “relevant medications” that your hand-off partner needs to know about. This would include IV solutions that might run out soon, high-risk medications the patient may be receiving, medications you are waiting to be delivered, or medications that require dosing in the next few hours. Since the chart is available with a complete list of medications, you do not want to force people to relist everything in a hand-off tool. However, some medications are important to the hand off and the duties your colleague is accepting as a result.

Look-alike/Sound-alike Medications
For 2010, this safety goal moved to the Medication Management standards (MM.01.02.01) and there are some important changes from 2009. TJC has eliminated the requirement to select your look-alike/sound-alike pairs from its Web site, allowing you to select these drugs from any source, including the ISMP list, if you choose. In fact, TJC even indicated that you should “consider” the ISMP list. Regardless, the most important aspect of this requirement is to accurately follow the guidelines set forth in your own policy. If the policy requires the use of supplemental labels or physical segregation of products, then you must do that wherever these products are stored or used. Often there is a policy vs. action variance in the pharmacy itself, commonly involving anesthesia trays and emergency kits. Given that this standard has three “A” elements of performance, even one lapse identified by the surveyor will result in an RFI not subject to a clarification audit.

2010 Medication-Related Safety Goals

Label All Medications on the Sterile Field
This safety goal continues to be scored on far too many hospital surveys. TJC has established this safety goal as an A element of performance so even one unlabeled syringe is a problem. The surveyors often do not look for this in the main OR area, but rather in the GI lab, or during ED/ICU bedside procedures. These areas can be the most problematic when making sure every medication and every basin of liquid on the sterile field has a label on it. Remember, even propofol requires a label.

The requirement to save the empty vials used to fill syringes until the conclusion of the procedure has been eliminated. Additionally, TJC has announced it is equally acceptable to draw, and then immediately label, or label and then immediately draw the medication. What is not acceptable is to draw three medications in a row, and then label all of them, or to label three medications in a row, and then draw those three. Each syringe and each basin must be individually labeled at the point of, or just before filling. During survey preparation, make sure procedural areas have access to labels. Many hospitals now include sterile labels and pens in their procedural packs and kits to expedite access.

There also are two new requirements in this safety goal. TJC added a new bullet point under EP 3, which requires the medication label to list the quantity of the medication, in addition to the strength and volume. Those facilities using preprinted medication labels will have to redesign them to allow for a quantity field. Secondly, the new EP 6 requires the immediate discarding of any medication found unlabeled. This should be an area of focus during mock surveys, as staff often apologize for not labeling a medication, yet continue to administer it rather than discard and redraw.

It is important to note that TJC staff have discussed a new survey feature called, “observed and corrected on site,” or OCO. If some standards noncompliance issues are immediately corrected, they have indicated the RFI will not count toward the adverse decision threshold consideration. This new OCO feature has yet to be fully discussed in Perspectives, but it is one that should be closely followed in 2010.

This safety goal remains, but the mandatory requirement to notify dietary of every patient placed on warfarin has been eliminated. Providing education to the patient and family is still requisite, but it need not be done by dietary. Additionally, despite the indication this past September that licensed independent practitioners had been removed from the mandatory education element of performance, in TJC’s December 2009 issue of Perspectives they added back in the requirement to educate all prescribers about the anticoagulation safety goal.

Keep in mind, one of the more frequently cited areas of noncompliance is when the hospital is not using its approved anticoagulation protocols. Because this element of performance is a “C,” the approved protocols must be followed for at least 90% of the patients being treated. Likewise, it is important to confirm that you have approved protocols. It is not uncommon to see orders for “dosing per pharmacy,” without a foundational protocol being used to perform that dosing calculation. Lastly, if your hospital has a home care department, note that TJC has deleted the anticoagulation safety goal as a home care requirement for 2010.

Medication Reconciliation
In early 2009 many hospitals were struggling with the medication reconciliation safety goal and the new features TJC had added for 2009. As this led to numerous RFIs, and a good deal of frustration, TJC decided to suspend scoring and redesign the requirement. I think everyone agrees this safety goal is valuable, the discharge reconciliation phase in particular, but precisely adhering to it in each case is difficult. Many hospitals expressed frustration with having to rely upon an oral interview with a patient and then be held to the quality and completeness of that information. In 2009 TJC mandated that medication reconciliation be performed at admission, transfer, and discharge wherever medications are used, including ambulatory procedural and radiology settings when IV contrast is used. To further complicate the issue, TJC mandated some very prescriptive requirements on how to perform medication reconciliation. In 2009 TJC also included nuanced requirements such as adding a note to a discharge list that advises patients to discard any older lists, and adding notes on transfer to other providers about who to call if there are questions about the list.

Looking forward, we have to assume medication reconciliation is going to continue as a requirement given its clinical value. Furthermore, it is likely to continue in three phases: at admission to an inpatient hospital or a continuing care outpatient clinic, at transfer in level of care, and at discharge, either to home or to the care of another provider. What may change, after meeting great resistance, are some of the detailed requirements for medication reconciliation taking place in procedural settings. Some improvement was made at the beginning of 2009 with the minimal-use definition, but more is needed. Read the first draft of the revised medication reconciliation safety goal once it is posted to TJC’s Web site, and if you have any questions or concerns, comment directly to TJC or through your professional association. TJC does take public comments into consideration when refining and ultimately approving any standard or safety goal, and this is a valuable opportunity to provide feedback.

For the time being, if your reconciliation process is working, my advice is to not change anything. If you have an electronic system that is not working well, it would be prudent to wait until the changes are announced before partaking in facility upgrades, as there is often great expense involved with IT and software enhancements. Once changes are announced, if you are using an electronic record, do provide feedback to TJC about the anticipated implementation date. A hospital’s flexibility and ability to change in a paper environment is much less difficult than in an EMR environment due to programming time and expense. For now, if you use paper forms and you think a revision would help expedite your processes, by all means create new versions of the form to better fit your needs.

Prevention of Surgical Site Infections
There are three new safety goals for prevention of infection, one of which deals with surgical site infection. NPSG.07.05.01, EP 7 establishes a requirement to administer antimicrobial prophylaxis according to evidence-based guidelines. This requirement is intriguing because there has been a core measure in this area for some time, but it lacked a mandatory component. This new element of performance is a C, thus TJC will be looking for a 90% compliance level. The guidelines have requirements for prophylactic antibiotic selection, time of administration in relation to the surgical procedure, and time of discontinuance. Given that this is now a safety goal, achieving a minimum of 90% compliance is essential.

TJC is not introducing a significant number of updates to the national patient safety goals for 2010. Nonetheless, it is important to educate staff on the new modifications, paying particular attention to changes in the safety goals, as these are the main emphasis of the surveyors’ training. With effective policies and thorough staff training, the negative ramifications of a poor survey can be avoided.


Now the owner of Patton Healthcare Consulting, LLC, Kurt A. Patton, MS, RPh, served as executive director of accreditation services at The Joint Commission for over seven years, until his retirement in December 2005. Before joining The Joint Commission, Patton was the deputy director for the Division of Strategic Initiatives and Managed Care in the New York State Office of Mental Health. Previously, he served as the administrator for a state-operated behavioral health managed care program and as the director of the Bureau of Health Services. Patton earned his bachelor’s degree in pharmacy and his master’s degree in institutional administration from St. John’s University.




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