Challenges to Complying with Medication Management Standards
November 2010 - Vol. 7 No. 11 - Page #72

Q & A with Darryl S. Rich, PharmD, MBA, FASHP
Surveyor, Division of Accreditation
and Certification Operations
The Joint Commission (TJC)



Pharmacy Purchasing & Products: Which medication management (MM) standard posed the greatest challenge to hospitals in 2009?
Darryl Rich: About one-third of organizations struggled with MM.03.01.01, the medication storage standard. The biggest challenge with compliance to this was ensuring medication security. We require organizations to keep medications stored according to the Centers for Medicare and Medicaid Services (CMS) interpretive guidelines for medication security, which are more stringent generally than state laws, and many hospitals are not familiar with these guidelines. For example, some organizations assume that a locked cart is fine, which is not the case. CMS is clear that locking a mobile cart by itself is not sufficient. It needs to be under constant surveillance, in a locked room, or tethered so it is not mobile. Therefore it is important for every pharmacy director to review the CMS interpretive guidelines.

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