Compliance Action Plan
The Priority Focus Area of Medication Management for the next Joint Commission visit requires that Nightingale Hospital plan its medication management process, label all medications, and increase patient safety when administering anticoagulant therapy.
In planning medication management processes, the Joint Commission requires hospitals to have a written policy that gives staff responsible for the management of medications and licensed independent practitioners access to a patient’s sex, age, diagnoses, allergies, sensitivities, current medications, height and weight, pregnancy and lactation information, and laboratory results. Further, the Joint Commission requires hospitals to implement the policy to make information about the patient available to licensed independent practitioners and staff responsible for medication management. Nightingale’s Patient Specific Information policy is sufficient for compliance because it not only outlines the required patient information to be made available to those involved with a patient’s medication management process, but also describes the specific tools used to make the information readily accessible. For example, Nightingale uses a Meditech MIS module to gather pertinent patient information and make it available to nursing, pharmacy staff, and physicians.
To improve the safety of using medications, the Joint Commission requires hospitals to label all medications that are not given to a patient immediately both in and out of the sterile field and in perioperative and procedural settings. Although staff interviews have revealed that many of the medication safety actions outlined in the Joint Commission’s Medication Management standards are practiced at Nightingale, for complete compliance with this standard and all of its elements of performance, it is recommended that Nightingale write a medication