MEDICATION MANAGEMENT

April 5, 2018
Valerie Henriques, MA, M.Ed., RN
Joint Commission Clinical Surveyor

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The Joint Commission

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 Session Objectives:

• To provide a framework for an effective and safe Medication

Management program.
• Evaluate the continuity of Medication Management from
procurement of medication through evaluation.

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 Medication Management
A safe Medication Management system addresses the following:
Planning
Selection and procurement
Storage
Ordering
Preparing and dispensing
Administration

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Monitoring
Evaluation

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 Medication Management-Planning
MM.01.01.01-The organization plans its medication processes.
• The organization has written policies that describe
medication management processes that is accessible to
Licensed Independent Practitioners (LIPs) and staff who are
involved in the patient’s medications. Policies are
implemented.
Policy-re: Medication Management
i.e. - acceptable orders (verbal, standing)

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- medication recall (how handle in organization)
- diversion of medication

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 Medication Management-Planning (cont.)

MM.01.01.03-The organization safely manages high-alert and

hazardous medications.
• High-alert medication:
-Involved a high percentage of error and/or sentinel events
-Medication that carries a higher risk for abuse or other adverse
outcomes
-Lists of high-alert medication are available from the institute of

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Safe Medication Practices (ISMP)

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 Medication Management-Planning (cont.)
• Examples of high-alert meds:
-controlled medications (Schedule 11 drugs)
-psychotherapeutic medications
-look-alike/sound alike medications
-medication with a narrow therapeutic range
• Hazardous medications are those in which studies in animals or humans
indicate that exposures to them have a potential for causing cancer,
developmental or reproductive toxicity, or harm to organs.

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i.e. Chloroform use in dental clinic
Lists are available from National institute for Occupational Safety and Health
(NIOSH).

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 Medication Management-Planning (cont.)
• For safe medication management, an organization must develop its own
list(s) of high-alert medication and hazardous meds based on unique
utilization patterns and its own internal data about medication errors and
sentinel events.
• Requirements
- Organization identifies in writing, its high-alert and hazardous
medications
-The organization has a process for the management high-alert and hazardous
medications.

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-Implements that process
Challenges in implementation - Not doing an organization wide sweep. All areas
where meds are stored i.e. dental, emergency carts, etc.

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 Medication Management-Planning (cont.)
MM.01.02.01-The organization addresses the safe use of look-
alike/sound-alike medications.
• The organization develops a list of look-alike/sound-alike medication it stores,
dispenses, or administers.
• Lists of look-alike/sound-alike medications are available from the institute of
Safe Medication Practices (ISMP).
-Applies to sample meds
• The organization takes action to prevent errors involving the interchange of

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the medication on its list of look-alike/sound-alike medications.
• The organization annually reviews and as necessary, revises its list of look-
alike/sound-alike medications.

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 Medication Management
Selection and Procurement
MM.02.01.01-The organization selects and procures
medications.
• Develop criteria for determining which medications are available for
dispensing or administering to patients.
• The criteria for selecting medications are approved by the organization and
indication for use, effectiveness and risk.
• Before using medications that are new to the organization, the organization
determines a method to monitor the response of the patient.
• The organization maintains a written list of medications, including strength and

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dosage, for dispensing and administering.
• The organization has a process to communicate medication shortage and
outages to LIP and staff.
• This applies to sample medications.

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 Medication Management-Storage
MM.03.01.01-The organization safety stores medications.
• The organization:
-Stores medication according to the manufacturer’s
recommendation
- Stores controlled (scheduled) medications to prevent
diversion
- Safely handles medications between receipt of LIPs or
staff
- Preventing unauthorized individuals for obtaining

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medications
- Removes all expired, damaged, and stores them
separately from medications available for administration

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 Medication Management-Storage (cont.)
MM.03.01.03-The organization safely manages emergency
medication.
• Patient emergencies occur frequently in health care settings. Organization
needs to plan how it will address patient emergencies and what
medications and supplies it will need.
• Organization decides which if any emergency medication and their
associated supplies will be readily accessible in patient care and based on
population served. Looking for a risk assessment.
• Emergency medications and their supplies are readily accessible.
• Whenever possible, emergency medications are available in unit-dose,

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age-specific and ready to administer forms.
(*Treat emergency medications with the same care for safety as it does medications in non-
emergency settings)

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 Medication Management-Storage (cont.)
MM.03.01.05-Safely controls medications brought into the
organization by patients and their families or LIPs.
The organization:
-Defines when these medications can be brought into the
health center by patients, their families or LIPs can be
administered
-Visually evaluates the medication integrity
-Informs the prescriber and patient if medications brought
into the organization by patients, their families, or LIPs are

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not permitted
Note: This element of performance is also applicable to sample medications

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 Medication Management
Ordering & Transcribing
MM.04.01.01-Medication orders are clear and accurate.
(This does not require the organization to have an electronic medical
record in place).
Look at how the organization uses electronic prescribing
• The organization has a written policy that identifies the specifics types
of medication orders that it deems acceptable for use:
-PRN orders
- Standing orders

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-Verbal orders-only in emergency
- Telephone orders
- Orders for medication related devices (i.e. nebulizer)
- Orders for herbal products

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 Medication Management
Ordering & Transcribing (cont.)
• The organization:
-Is responsible for reducing the potential for medication errors
and misinterpretation of medication orders
-Determines the required elements of a medication order, the
type of medication orders that are acceptable
-The action to take when medication orders are incomplete,
illegible and unclear
-Has a written policy that identifies the specific types of
medication orders that are deemed acceptable
• For PCMH organizations:

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1. uses prescribing process for at least 50% of allowable prescriptions
2. uses a computerized order entry system for at last 60% of medication
orders

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 Medication Management
Preparing and Dispensing
MM.05.01.01–Review the appropriateness of all medication
orders for medications to be dispensed in the organization.
All medication orders are reviewed for the following:
- Patient allergies for potential sensitivities
- Existing or potential interactions i.e. food+meds
- Impact as indicated by lab values
- The appropriateness of the medication, dose, frequency and route

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- All concerns issues or questions are clarified with the individual

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 Medication Management
Preparing and Dispensing (cont.)
MM.05.01.09-Medications are labeled.
• A label on every medication is a standard of care by the pharmacy
profession and is required by law and regulation.
• Medication containers are labeled whenever medications are prepared but
not immediately administration.
An immediately administered medication is one that an authorized staff member
prepares or obtains, takes directly to the patient, and administered to that patient
without any break in the process.

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• This element of performance is also applicable to sample medications.
• Information on medication labels is displayed in a standardized format, in
accordance with law and regulation and standard of practice.
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 Medication Management
Preparing and Dispensing (cont.)
MM.05.01.15 -The organization safely obtains medication when it does
not operate a pharmacy.
• If the organization does not operate a pharmacy, the organization has a
process for obtaining medications for a pharmacy or licensed pharmaceutical
supplier to meet patient needs. This process is implemented.
MM.05.01.17 -The organization follows a process to retrieve or
discontinued medication.
• The organization:
-Has a written policy describing how it will retrieve and handle medications
within the organization that are recalled or discontinued for safety reasons.

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-Implement its policy or retrieving and handling medications when they are
recalled or discontinued.
-When required by law and regulation or organization policy-the
organization informs patients that their medication has been recalled or
discontinued.
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 Medication Management
Administration
MM.06.01.01-The organization safety administers medication.
The organization:
• Defines, in writing LIPs and clinical staff disciplines that are authorized to
administer medications, with or without supervision, in accordance with law
an regulation.
• Before administering a new medication, the patient or family is informed
about any potential clinically significant adverse drug reaction or other
concerns.
• Verifies the five R’s (patient, drug, dose, route, time)

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• Verify that the medication has not expired
• Multi-dose injectable that are used for more than one patient when they are
opened, should be discarded within 28 days of opening or according to
manufacturer's recommendations, whichever is more stringent.

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 Medication Management
Monitoring
MM.07.01.01 & MM.07.01.03 –
The organization monitors patients to determine the effects
for their medication(s).
The organization responds to actual or potential adverse drug
events, significant adverse drug reactions, and medication
errors.
• The organization:
-Monitors patient’s perception of side effects and effectiveness of

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medications.
-Monitors the patient’s response to medication(s) by taking clinical
info., relevant lab value etc. (monitor first dose)
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 Medication Management
Monitoring (cont.)
MM.7.01.03-The organization responds to actual or potential
adverse drug events, significant adverse drug reactions, and
medication errors.
• The organization:
-Has a written process to respond to actual and potential adverse
drug events, significant adverse drug reaction, and medication error.
-Complies with external and internal reporting requirements for

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actual or potential adverse drug events error, significant adverse
reaction, and medication.
-Implements its process for responding.

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 Medication Management
Evaluation
MM.08.01.01-The organization evaluates the effectiveness of
its medication management system.
• The organization:
- Collect data on the performance of its medication
management system
- Analyzes data on medication management system
- Compares data over time to identify risk points patterns,
trends and variations of medication management system

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Note: This evaluation include reconciling medication info.
(NPSG.03.06.01)

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 Medication Management
2017 Top Non-compliant Ambulatory Care
Standards for Health Centers
• MM.01.02.01 EP 2: The organization takes action to prevent errors
involving the interchange of the medications on its list of look-alike/sound-
alike medications.
• Note: This element of performance is also applicable to sample medications.
• MM.03.01.01 EP 2: The organization stores medications according to the
manufacturers' recommendations.
• Note: This element of performance is also applicable to sample medications.

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• MM.03.01.01 EP 6: The organization prevents unauthorized individuals
from obtaining medications in accordance with its policy and law and
regulation.
• Note: This element of performance is also applicable to sample medications.
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 Medication Management
2017 Top Non-compliant Ambulatory Care
Standards for Health Centers
• MM.03.01.01 EP 7: All stored medications and the components used in
their preparation are labeled with the contents, expiration date, and any
applicable warnings.
• Note: This element of performance is also applicable to sample medications.
• MM.03.01.01 EP 8: The organization removes all expired, damaged, and/or
contaminated medications and stores them separately from medications
available for administration.

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• Note: This element of performance is also applicable to sample medications.
• MM.03.01.03 EP 2: Emergency medications and their associated supplies
are readily accessible. (See also PC.03.01.01, EP 8)
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References:

• CAMAC - Medication Management (MM) Chapter

• Institute for Safe Medication Practices (ISMP)
• National Institute for Occupational Safety and Health
(NIOSH)

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 Questions

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Thank you for partnering with us in
your continuous journey to provide
high quality care for health center
populations.

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The Joint Commission Disclaimer
• These slides are current as of April 5, 2018. The Joint Commission and the
original presenter reserve the right to change the content of the information, as
appropriate.
• The Joint Commission reserves the right to review and retire content that is not
current, has been made redundant, or has technical issues.
• These slides are only meant to be cue points, which were expounded upon
verbally by the original presenter and are not meant to be comprehensive
statements of standards interpretation or represent all the content of the
presentation. Thus, care should be exercised in interpreting Joint Commission
requirements based solely on the content of these slides.

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• These slides are copyrighted and may not be further used, shared or distributed
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