Inpatient Hospital Pharmacy related Q&A as posted on JCAHO website

Securing Flushes or Diluents

Q:  Does normal saline or sterile water vials used for flushing or diluting medications require the same level of security as medications?
 
A:  The FDA classifies some of these products (e.g., sodium chloride and heparin flushes) as "medical supplies" rather than medication. Applicability of the Medication Management standards to a specific product is based on FDA classification which is usually noted on the product label.

Storage of Intravenous Solutions

Q:  Can basic IV solutions be stored in and distributed by Materials Management?
 
A:  Yes. While these products are defined as medication, Joint Commission standards do not require that they be controlled or distributed by the Pharmacy however, Medication Management standards still apply.

Minimum Patient Information - Medication Effective June 29, 2005

Q. Does the minimum required patient information for medication management need to be documented in a single form?

A. No.  Standard IM.1.10 requires that the information be accessible.  In other words, all staff involved in medication ordering, preparation, dispensing, administration, and monitoring need easy access to this information.

Labeling Medication for Anesthesia- Effective August 15, 2005

Q:  Do we have to label medications used during anesthesia or sedation?
 
A:  Anytime one or more medications are prepared but not administered immediately (prepared by a person who takes the medication directly to a patient for administration without a break in that continuum), the container (which may be a bag, syringe, bottle, or box) must be labeled.
 
At a minimum the labeling must include drug name, strength, amount (if not apparent from the container), expiration date if not used within 24 hours, expiration time if expiration will occur in less than 24 hours, and the date prepared and the diluents for all compounded IV admixtures.

Security of Anesthesia Cart Medications- Effective August 15, 2005

Q:  Can an anesthesia cart containing medication be left unlocked in an OR suite between cases?
 
A:  If the individual operating room is part of a larger OR unit that is manned at all times in a fashion which monitors access to the operating room and assures constant surveillance of the anesthesia cart to prohibit access by unauthorized individuals - locking of the cart between cases would not be required. 
 
After hours when the OR unit is not manned in a like manner, the carts must be properly secured.  Whether the carts are locked or unlocked, they must be stored in a secured area which prohibits access and tampering by unauthorized individuals (e.g., in a separate locked room or in the secured OR unit where unauthorized access is prohibited.)

Reordering Medications at Transfer- Effective August 17, 2005

Q:  If a patient is transferred to the floor from ICU or from any unit to any other unit in the organization, must medications be reordered?
 
A:  No, unless it is required by your organization's policy.

Medication Refrigerator Temperature Logs-  Effective August 15, 2005

Q:  Are we required to maintain temperature logs for medication storage refrigerators and freezers?
 
A:  Joint Commission does not specifically require temperature logs for refrigerators and freezers used for medication storage. Standard MM.2.20 requires that medications be stored under necessary conditions to ensure stability. EC.6.10 additionally requires that you describe and implement processes to maintain and monitor equipment performance. If your organization chooses to use temperature monitoring to achieve this, the monitoring method must track temperature in an ongoing fashion to indicate whether or not internal temperature has deviated from the required ranges for all drugs stored. In addition, the organization should have a defined process outlining disposition of medication from a refrigerator or freezer which has deviated from the recommended temperature range.

Define "Concentrated Kcl"- Effective August 04, 2005

Q:  What is considered "concentrated" in terms of potassium chloride? We have 100ml bags of potassium chloride in strengths of 20 and 40 mEq. The bag label states that it is concentrated. Must these be kept out of patient care areas?
 
A:  Strengths of 2 mEq/ml or greater (specifically, vials of 20mEq/10ml and 40mEq/20ml) are considered concentrated. The bags noted above are not considered