Melissa L. Nelcha
AFT2- Task 1
Western Governors University
October 25,2013

The Joint Commission has identified four distinct areas of concern within our accreditation audit. They are Communication, Information Management, Infection Control and Medication Management. While each of these is important, and vital in running Nightingale, the focus of this Summary will be on Medication Management. The reasons are as follows: * Errors can lead to increased hospital stays, possible lawsuits, and increased mortality rates, all of which affects our reputation within the community and elsewhere. * Due to the severity of the possible outcomes from medication errors, our company could end up having to pay out large sums of money to deal with repercussions of these errors in legal fees, etc. * Increasing numbers of Adverse Events can lead to a moratorium set on our facility, wherein we would not be allowed to accept any new patients, thereby losing untold amounts of money. A step this drastic can take years to fully recover from. * Having to legally inform the public of each and every adverse event coming from a Medication error could also cost us untold amounts of revenue. The Joint Commission Standard focused on in this summary will be Medication Management. There are three areas covered within the Medication Management Criteria. * Planning Medication Management processes * Labeling of Medications and devices used to administer them * Reducing patient harm in conjunction with Anticoagulant Therapy (Warfarin, Coumadin, Heparin)

Standard MM.01.01.01: The hospital plans its medication management processes * We are in compliance with both Elements of Performance (EP’s), which are : 1. The organization has a written policy that describes that the following information about the patient is accessible to licensed independent practitioners and staff who participate in the management of patient’s medications: age, sex, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, laboratory results, any additional information required by the organization. 2. The hospital implements its policy to make information about the patient accessible to licensed independent practitioners and staff who participate in the management of the patient’s medications.
Standard NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings * We are in compliance with 6 out of 8 EP’s. The ones not in compliance are as follows: 1. In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container (this falls under Medication Management, Information Management and Patient Safety). A. Documentation is imperative in this situation. Although we do not normally transfer medications to another container once they come from Pharmacy, we must have documentation to support us when we do. The documentation would be the responsibility of the Unit Manager and Risk Management Director and would have to be done immediately, or within a two hour window at most. Our Risk Management Team and MSO (Medication Safety Officer- Pharmacy Director) would review these documents quarterly, and implement changes as needed; this is in conjunction with quarterly chart and med cart/room audits. The Nightingale Patient Safety and Clinical Quality Committee would then implement continuing education or in-services for the staff, as called for in the prior findings. I. New Policies and Procedures addressing this EP will be implemented within 30 days with a 60 day window of completion. P&P tracking forms will be used to certify compliance. Date of compliance: 60 days 2. Immediately discard any medication or solution found unlabeled (this falls under Medication Management, Information Management and Patient safety). A. This is another situation that we do not often find ourselves in. However, as stated before, documentation is key. We would follow our already in place policy concerning the destruction of medications, and have two licensed nurses, in addition to the Unit Manager, witness the medications being destroyed. All three staff would then sign to verify that they were indeed destroyed, and it would then be filed in the Floor Chart and a copy faxed to the Pharmacy. This would have to be done before the end of shift on the day found. This is the responsibility of the Unit Manager, and if it is not done, and reported by the following shift, it is a write up worthy offense. In addition to the P&T Committee and the Medication Variance Committee, the Nightingale Patient Safety and Clinical Quality Committee and MSO would review these quarterly as well, and would implement in-services to educate our staff about the dangers of not labeling medications appropriately. I. New Medication Destruction Forms are to be implemented within 30 days with a 60 day window of completion. These forms will be added to the Unit Management Charts and audited quarterly to ensure compliance. In-service tracking has the same time frame with appropriate tracking forms utilized. Date of compliance: 60 days It is important to note that although we are technically not in compliance regarding these specific issues, we have not been cited, nor have there been adverse incidents as a result of failure on the part of Nightingale or its staff. We need to take care of these issues before they become a cause for concern.

NSG.03.05.02: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. * We are in compliance with 5 out of 8 EP’s. The ones not in compliance are as follows: 1. Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available (this falls under Medication Management and Patient Safety). A. Correct ordering of medications is the responsibility of the Physician and clinical pharmacy specialist, who personally oversees the warfarin dosing services. Physicians will be notified of changes in the ordering, and the documentation will be tracked by the clinical pharmacy specialist. The Assistant Director of Pharmacy would assist the clinical pharmacy specialist in ordering, with the Director of Pharmacy performing quarterly Warfarin supply audits for compliance purposes. I. Pharmacy Order Tracking Software will be installed and utilized within 60 days. This Software cuts down on medication errors due to inability to read prescription correctly and automatically updates the medical charts for HIPAA and Joint Commission Compliance. The Software Company offers free training to Pharmacists and Clinicians, as well as online support. Training and software will be completed and in use at the end of the 60 day period, with the Director of Pharmacy submitting employee training tracking forms to the P&T Committee a week prior to official utilization. Date of compliance: 90 days. 2. When Heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing (this falls under Equipment Use, Medication Management and Patient Safety). A. We need to work with Central Supply and make sure we have pumps readily available for usage. The Central Supply Director and Assistant Director of Pharmacy would be responsible for the initial ordering of proper equipment, with the continuous supply monitored by the Central Supply Director. Weekly meetings between the Central Supply Director and Assistant Director of Pharmacy would take place; addressing the pump supply and ordering recommendations (this ensures there is enough equipment in house to take care of these needs). These meeting slips would be signed by both and given to the Director of Pharmacy for documentation tracking. Quarterly supply audits will be done by the Director of Pharmacy to ensure compliance. I. Ordering will be completed within 30 days. The Director of Pharmacy will be in charge of tracking orders, and will submit reports to the P&T Committee at the end of the 30 day period. Once the supplies are ordered and in stock, The Risk Management Director will update the Policy and Procedure Manuals within the next 30 day period; after which the MSO will Audit Policy and Procedure Manuals and reporting findings to P&T Committee Meeting. Within 60 days, the Programmable Pumps will be ordered and utilized, as well as updated in Manuals to be in compliance. Manual and Chart Audit Tracking Forms will be used to check compliance. Date of compliance: 60 days. B. The clinical pharmacy specialist will hold mandatory staff meetings for all licensed practitioners, both in house and independent, to make them aware of new procedures for Warfarin dosing; attendees will be required to sign that they were in attendance. The MSO will audit in-service attendance bi-yearly to make sure we are in compliance. II. Mandatory staff meetings will be started in the next 30 days, with a completion date of 60 days. Continuing Education Unit tracking forms will be used to maintain compliance. Date of compliance: 60 days C. This will also be implemented in new hire training by the Assistant Director of Pharmacy. In-services and orientation training is easy to track with attendance verified by signature. The Corporate Compliance Officer will be in charge of keeping these records up to date, and will audit new hire orientation documentation quarterly. I. Training must be completed within 30 days of hire. New hire orientation packets and tracking forms will be used and we will be in compliance within the next 90 days. The Human Resources Manager is responsible for auditing this information monthly, and any discrepancies must be reported to the Director of Nursing and the Director of Pharmacy. Date of compliance: 90 days 3. Provide education regarding anticoagulant therapy to staff, patients and families. Patient/Family education includes the following: The importance of follow up monitoring, compliance, drug-food interactions and the potential for adverse drug reactions and interactions (this falls under Communication, Information Management, Medication Management, Orientation and Training and Patient Safety). A. This requires information to be handed out to patients and families, and would require a signature of the responsible party, verifying that they were given the information. Thorough flyers are recommended. This is the responsibility of the Physician and Discharge Planning Team, with the assistance of the Risk Management Director. Additional information will be presented and voted on by the P&T Committee and will begin to be implemented within 60 days. The Executive Discharge Planner will then take the responsibility of making sure all of the packets handed out on date of discharge have the new information and instructions included. From that point, the Risk Management Director will audit the department quarterly, as well as random discharge packet audits, to make sure they are staying in compliance. I. These changes will begin to be implemented within the next 30 days, and will be effectively in complete compliance in 90 days. Discharge Packets will be updated and utilized within this time frame. Date of compliance: 90 days. B. The education for the staff would be the responsibility of the P&T Committee and the Medication Variance Committee. Their recommendations are what drive the Nightingale Patient Safety and Clinical Quality Committee’s actions concerning continuing education and in-services needed. Documentation to support decisions will be given to the clinical pharmacy specialist, whose job is to administer training to staff concerning warfarin policies, among others. Necessary staff will be required to attend bi-yearly training on anticoagulant therapies, as well as any new policies put into place by Nightingale. The MSO will conduct twice yearly thorough audits, to make sure all of the current applicable staff is within in-service compliance. I. In-service tracking forms will be used, and educational classes started with a 30 day implementation window. Date of compliance: 90 days.

On average, Nightingale had 3.4 instances of adverse drug events from the administration of Anticoagulant Therapy in the previous 12 months (with February and March having 6 each). April was the only month with 0, and this is what we should have each and every month. By making some slight changes, and following protocol strictly, there is no reason that we cannot bring those numbers down. As follows are the recommendations for compliance: The Joint Commission recommends that all Warfarin orders not be administered until a baseline INR is done, and then administered, or not, according to the results. Nightingale has a very impressive protocol already in place addressing this, and it has been followed accordingly. There are additional recommendations concerning the use of anticoagulant therapy. While these are not “official”, they are inexpensive and relatively easily implemented, and can assist in staying in compliance, and reducing our liability. * Educating the patient, and the staff, about implications of diet and supplements on the effectiveness of treatment; also making sure that the patient is aware of dangers associated with drinking alcoholic beverages. * Making sure that at onset of admission, the dietary department is aware of the patient being on Anticoagulant Therapy in order to give them food in accordance. * Being thorough in admission stage, and gathering all information about medications being taken at home, drawing special attention to supplements, can increase the effectiveness as well. Many people do not consider supplements to be “real” medication, therefore getting that information from them is very important. * A member of the Risk Assessment Team will follow up with the patient within three days of discharge via personal telephone call, and will answer any questions that they may have about their discharge orders, etc. These recommendations may seem lengthy, but can be implemented, and tracked relatively easily. By adhering to these changes, we stay within compliance guidelines, and decrease the chances of adverse events, and state sanctions; both of which can irreparably harm our business. In order to be successful at implementing, and following, these recommendations, we have to work as a team.

References
Nutesco, E. A. (2013). Oral anticoagulant therapies: Balancing the risks. American Journal of Health Systems Pharmacy, 70(10), doi: 10.2146/ajhp130040
Moll, S. (2012, February 27). [Web log message]. Retrieved from http://professionalsblog. clotconnect.org/2012/02/27/new-accp-guidelines-–-dvt-and-pe-highlights-and-summary/
Important information when you are taking: Coumadin and vitamin k. (n.d.). Retrieved from http://ods.od.nih.gov/pubs/factsheets/coumadin1.pdf

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