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Hospital Pharmacy Volume 38, Number 10, pp 977­980, 989 2003 Wolters Kluwer Health, Inc.

Ask the Joint Commission

More on the Requirements of the Medication-Related National Patient Safety Goals for 2003­2004

Darryl S. Rich, PharmD, MBA* This column addresses questions from readers about any issue, process, standard, or future direction of the Joint Commission, whether it relates to home care, the hospital, or other practice environments. The objective is to give you a better insight into the Joint Commission accreditation process in your own practice site. Any question is fair game. Readers are encouraged to submit questions to Darryl S. Rich, PharmD, MBA, Joint Commission, Division of Accreditation Operations, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Fax: 630-792-4752. E-mail: [email protected] Please indicate that you are submitting your question for this Hospital Pharmacy feature. mean "physical therapy" if this meaning has been established, but PT should not then be used as an abbreviation for "protime." On the other hand, an unacceptable abbreviation is one that is dangerous and should never be used. Some organizations may refer in policy to a printed source for the meaning of medical abbreviations, acronyms and symbols (such as Stedman's), rather than create their own list. It should be remembered that a list of acceptable abbreviations is not required by the Joint Commission (it was prior to 1993); however, a list of unacceptable abbreviations is required by the National Patient Safety Goals. The requirement to standardize all abbreviations, acronyms, and symbols (IM.3.10) can be achieved without creating a list. (4) Our hospital has implemented a list of abbreviations "not to be used." Our pharmacy computer system allows a limited number of characters in the dose and dose descriptor fields, as do most systems. There are a small number of medications (penicillin, interferon, etc) that are dosed in millions of units. We are forced to use MU as the dosing units in the system. Would this be considered an infraction of the National Patient Safety Goal requirement? (5) With regard to the institution's list of abbreviations that cannot be used, is it permissible to stipulate that certain abbreviations are acceptable if they are used in a com-

(1) Is recognition of the patient (without a picture in the room) acceptable as one of the two patient identifiers for National Patient Safety Goal recommendation 1a? We have said that recognition is acceptable -- after a period of time -- in the home care and some other settings, because the same staff nurse routinely takes care of the same patient. However, this is not an acceptable approach in hospitals because of the high number and rapid turnover of nursing staff and the frequent use of per-diem or contracted personnel. (2) Can an institution use different patient identifiers for different processes (eg, name and date of birth for laboratory and name and patient identification number for medication administration)? Yes, you can use different patient identifiers for different

*Associate Director, Surveyor Development and Management, Division of Accreditation Operations, Joint Commission on Accreditation of Health Care Organizations.

processes as long as this is specified in policy and is consistently followed for each process. The identifiers cannot be switched on a patient-bypatient basis for the same process, and different individuals cannot use different identifiers for the same process. Furthermore, every patient must display all the identifiers for all processes. In the example provided, the patient would be required to have all three patient identifiers (name, date of birth, and patient identification number) on his or her wristband or at the bedside. (3) If an abbreviation is not on the unacceptable list, does it mean that it is acceptable? It really depends on the policy of your organization. A hospital can state that any abbreviation not on the unacceptable list is acceptable. Some hospitals have both approved (acceptable) and unacceptable lists of abbreviations, acronyms, and symbols. An approved list may signify how all staff should interpret an abbreviation. For example, an order for "PT daily" may be assumed to

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puter-generated order but cannot be used in a handwritten order? It is apparent to us that some errors associated with abbreviations are due in part to misinterpretation of handwriting. When used in a computergenerated order, misinterpretation of an abbreviation and the resulting error is less likely (mcg vs mg). While it may be true that the risk associated with dangerous abbreviations, acronyms, and symbols is greater with handwritten documentation (because it adds another risk variable), the incidence of errors is still significant when these abbreviations are used in printed and electronic documentation. However, the current and 2004 National Patient Safety Goal requirement related to lists of abbreviations that are not to be used currently applies only to handwritten items and not to printed or computer-generated documents. This decision was made because changes to printed forms and computer systems take considerable time, and the costs may be prohibitive. Once a sufficient number of vendors remove such dangerous abbreviations from their computer software, we probably will change our position on this matter. Currently, we are encouraging the removal of such dangerous abbreviations from printed and electronic media, but are not scoring it. One final note: The requirement applies to all patient communications (eg, progress notes) and not just medication orders. (6) We have "U" on our list of unacceptable abbreviations. Could MU be considered a different abbreviation even though U is part of it? Yes, it is considered a different abbreviation. (7) At our hospital, we have a "Do Not Use" abbreviation list. Some physicians write the medica-

tion abbreviation after the generic name when writing an order (eg, Cytarabine [ARA-C]), even if the abbreviation is on the "do not use" list. This would seem acceptable, since it adds another double check into the system. Is it acceptable by JCAHO? We would not consider this in violation of the goal's requirement unless it was specifically prohibited in the organization's policy on how the list is to be used. (8) In your last column, you discussed the new requirement for a list of abbreviations, acronyms, and symbols that should not be used. You indicated that the list was required to include 6 to 10 JCAHOspecified abbreviations, acronyms or symbols. Where can I find these abbreviations, acronyms or symbols? The list will be available on our Web site this month for implementation in January 2004. In 2003, organizations can select any number of abbreviations, acronyms, and symbols for their own lists of abbreviations that should not be used -- based on information in the literature and a review of incident reports and orders in their organization. (9) Based on a review of orders and incident reports, we have documented problems with the following abbreviations at our hospital: · "U" for units · "MgS04" and "MS04" · "gr" for grains · trailing decimals and preceding zeroes · "SNP" for nitroprusside · "PEA" for procainamide We proposed this as our unapproved list to our senior leadership. They are concerned that JCAHO will not count the trailing decimals or preceding zeroes as abbreviations. I believe that JCAHO would view this item as an "improvement of

communication" and find that the list satisfies the new requirement for 6 to 10 abbreviations, symbols, or acronyms. Please let me know JCAHO's position on this. Strictly speaking, dangerous "trailing zeros" and "absence of leading zeros" are not abbreviations, acronyms, or symbols, but they are important safety-related documentation conventions that the Joint Commission considers included under this goal. So, yes, this will count as one of the 6 to 10 abbreviations, acronyms or symbols on your list. (10) Please clarify the process for reading back verbal/telephone orders as required by the JCAHO National Patient Safety Goals. Are receivers of verbal and telephone orders expected to read-back as they are writing the order or after they have written the order -- particularly when multiple drug orders are being prescribed? It must be done after they have written the order, not during writing or prior to reducing it to writing. (11) When a pharmacist intervenes in an order and recommends that the physician change a drug order, what "read back process" would you recommend with regard to the National Patient Safety Goals? If the pharmacist is allowed by medical staff rules to take and enter verbal/telephone orders into the medical record, then the pharmacist would write down the changed order in the order section of the patient record (if readily available during the call) or on a separate piece of paper. The pharmacist should then say: "To make sure that it is correct, let me read back the order that I will put into the chart as a verbal order from you: Piperacillin 3 (t-h-r-e-e) grams IV every 4 (f-o-u-r) hours." If taken on a piece of paper, the pharmacist will need to go to the chart


Volume 38, October 2003

Ask the Joint Commission

and transcribe the order from the piece of paper to the chart. The entry in the chart should be validated against what is on the piece of paper. The entry in the chart should not be made from memory. If the pharmacist cannot take the order, then the pharmacist needs to either transfer the call to the person on the floor who can take the telephone order, or ask the physician to call the order into the unit. In either case, the person receiving the order would perform the "read back" procedure. (12) For the National Patient Safety Goal requirement: "Drug concentrations are standardized and limited . . ." How does this relate to the NICU population? Drips and continuous infusions for this population are traditionally weight-based calculations (ie, Rule of 6) to minimize fluid. Are there particular guidelines on how to meet the intent of this standard for this population? (13) I hope that you can address my question regarding standard concentrations for drips for pediatrics. At our institution, we feel that we have a unique system in place. We have a Microsoft Excel program that calculates the drug amount that should be placed in 100 mL (based on the Rule of 6) for every patient up to 130 kg. We consider this a standard because all health care providers prescribing, preparing, and administering this drips have access to our Excel program. It is in the PICU, Pharmacy, etc. This means that there is a standardized way to calculate the drip and every one will arrive at the same drug amount to use. The "Rule of 6" is a way of calculating drip medications so that 1 cc = 1 microgram/kilogram/minute. Specifically, 6 x body weight (in kg) added to 100 mL of diluent, when administered at 1 mL/hr delivers 1 mcg/kg/min. The "Rule of 6" was

originally developed for emergency, "code," or crisis situations in which people find it difficult to concentrate on the calculations needed to determine the proper dose, rate, and amount of diluent. However, it is now routinely used for many pediatric IV drips, especially critical care drugs. There are two problems with the "Rule of 6." First, it is only an approximation and can in some cases lead to dosing errors. Fluid overload problems have occurred when the "Rule of 6" has been used. In fact, it is for this very reason that the Institute for Safe Medication Practices is opposed to using the "Rule of 6." Second, the basic approach is designed to keep the volume of diluent and rate of infusion constant while varying the drug concentration. This approach is in direct contradiction to the National Patient Safety Goal requirement for having a limited number of standardized concentrations of drugs. The National Patient Safety Goal requirement is to keep the concentration constant and vary the amount of diluent and/or the rate of infusion. Thus, any organization that uses the "Rule of 6" is not in compliance with this National Patient Safety Goal and will receive a Type I recommendation. Pharmacies need to provide nurses with mcg/kg/min dosing charts for pediatric critical care drugs so that nurses can use standardized concentrations from commercially available premixed solutions or pharmacy-prepared products. ISMP recommends making the dosing charts available on preprinted solution labels that are affixed to all IV bags. While this may be a bit extreme, it is important to have the dosing charts available wherever pediatric drips are ordered by prescribers or prepared by nurses. We recognize that there may be

a much higher number of drug concentrations available in pediatrics. In such cases, special precautions should be taken to avoid dosing errors. For example, the order should specify actual drug dose, not volume, and the dose calculation -- including the specific data elements such as the person's weight, dose per unit weight, and rate of administration -- should be written out as part of the order. The reason for this is to provide enough information for the pharmacist who is reviewing the order and preparing the medication, and the nurse administering the medication, to recalculate the dose as a check. (14) In our hospital, cardioplegia solution is being compounded for cardiovascular surgery by the pharmacy. However, there are six cardiovascular surgeons and six different requested "formulas" for the cardioplegia solution. Ultimately, they all do the same thing: Stop the heart. Would you see this as noncompliant with the National Patient Safety Goal requirement ("There is a limited number of standardized concentrations. . .")? Unless they can defend the variation based on patient need, this is not in compliance with the goal's requirement. We would expect that only one or two formulas for cardioplegia solution be available, rather than one per surgeon. (15) How is the appropriate number of concentrations determined, for example, with potassium chloride, to meet the National Patient Safety Goal recommendation for having a limited number of standardized concentrations. Also, how is this scored? There is no specific number of concentrations that the surveyor determines or seeks. The question will be: Can a physician order any

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strength or concentration of potassium chloride they want and is it admixed and dispensed in that concentration or must they select from a predetermined list of standardized concentrations? Do nurses vary the rate of infusion of a standardized concentration of potassium chloride or do they admix a different strength of the product to administer to the patient as a particular rate? (16) Our facility has standardized concentrations for many IVs. However, there are times when we need to double the concentration because of fluid restrictions. Is that acceptable? Certainly you can have a limited set of standard concentrations for normal patients and another limited set of standard concentrations for fluid-restricted patients and pediatrics. We will also accept the use of nonstandardized concentrations when they are used infrequently, there is a specific need for a specific patient, and the proper dose cannot be administered using the standard concentrations. (17) The dialysis unit at our hospital is run by an outside company. They use potassium chloride packets (9 g, Edlaw Pharmaceuticals, Inc., Farmingdale, NY); this product is actually labeled as a legend device by the FDA. They add this to a bath to create a solution that results in a concentration gradient across the dialysis membrane. I am told that this procedure is done in all dialysis units. Is JCAHO familiar with this type of product? How is its presence in the dialysis unit viewed in terms of the National Patient Safety Goal requirement prohibiting the storage of concentrated electrolytes in patient care areas? We are not familiar with this product, but it would not fall under the requirements for not storing con-

centrated electrolytes. The rationale for the National Patient Safety Goal and its requirement to not store concentrated potassium chloride on patient care units is that the vials are often mixed up with normal saline, heparin, or other products and given as a bolus, killing the patient. I cannot foresee this happening with these packets. Furthermore, the FDA classifies this product as a legend device. That means that it does not meet the definition of a medication, and the goal is specifically related to highalert medications. (18) Concerning storage of concentrated electrolytes in a night cabinet: We use a Pyxis Medstation as our night cabinet and it is located in an administrative wing, not in a patient care area. We require that the nurse supervisor, if necessary, admix the concentrated electrolyte on a clean surface in the night cabinet area, properly label the admixed bag, and deliver only the diluted IV bag to the patient care area. The concentrated vial must stay in the night cabinet area. Our CSR representative reviewed this process and felt that it met the National Patient Safety Goal requirement because it was not in a patient care area. Did I understand you to say that we cannot keep concentrated electrolytes in a night cabinet under any circumstances? No. The National Patient Safety Goal only prohibits storage of concentrated electrolytes in patient care areas. I agree with your CSR representative ­ your process meets the intent of the National Patient Safety Goal Requirement 3a. However, concentrated electrolytes cannot be stored in automated storage and distribution devices that are located in patient care areas, unless special measures are taken (restricted access, separate bin with access to no other drugs in the tray, special label-

ing). However, having nurses prepare IV admixtures for a product that comes in so many strengths in premixed form has to be questioned. You may not be dispensing (or have available) medications in the most ready-to-administer form as required by standard TX.3.5.3 and/or you may not be meeting the requirement for having a limited number of standardized concentrations. Therefore, although you may be in compliance with this particular NPSG requirement, you may not be in compliance with other NPSG requirements or JCAHO standards. (19) Some PCA pump manufacturers have placed head height restrictions for the use of tubing sets with antisiphon valves for free-flow protection. Does a head height restriction satisfy the National Patient Safety Goal recommendation for free-flow protection with infusion pumps? No, it does not. Head height restrictions alone are not adequate. There must be intrinsic free-flow protection built into the sets used in the pumps. (20) I have heard that the National Patient Safety Goals for 2004 are the same as those for 2003. Is that correct? Yes and no. All of the 2003 National Patient Safety Goals and their requirements have been carried over into 2004. There is one change with respect to the requirement for a read-back verification process. It has been extended to include not only verbal orders, but also the verbal reporting of critical laboratory test results. In addition, there is a seventh goal and two corresponding requirements. The seventh goal is to reduce the risk of health careacquired infections (also called nosocomial infections). The two requirements for this seventh goal are: (a) to


Volume 38, October 2003

Ask the Joint Commission

comply with the current CDC hand hygiene guidelines; and (b) to manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health careacquired infection. I would expect that the first requirement related to the CDC hand hygiene guidelines would apply to pharmacy staff, particularly those who handle, prepare, or compound medications.

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