vv WP Joint Commission International JCI Accreditation Standards for Hospitals, 7th Edition Draft Standards for Field Review Proposed New Standards and Requirements Note: This document does not include all standards for the JCI Accreditation Standards for Hospitals, 7th Edition. The standards in this document are the proposed new standards and proposed new requirements for existing standards. New standards and new requirements are underlined. In addition, some standards in this document do not have new requirements and are not included in the field review; however, some of these standards have been revised for the purpose of clarifying requirements and expectations. These revisions are also underlined.{©2019 Joint Commission Internationa CT Stundasde for Hoopsale Dist sone ISG3-PSG.32 International Patient Safety Goals (IPSG) Standards, Intents, and Measurable Elements Goal 3: Improve the Safety of High-Alert Medications Standard IPSG.3 The hospital develops and implements a process to improve the safety offhigh alest medicatibus. ®) Standard IPSG.3.1 The hospital develops and implements a process for Hesaf= use of loeRalice/sonnd-alike medications. ® Standard IPSG.3.2 ‘The hospital develops augidmplerientaliyprocess to mihuaze tie safe waelof concentrated clectzolytes. Intent of IPSG.3 through IPSG.3.2 ‘When medications are part of thepatienstregiment plan, appropsiate management is csitical to ensuing patient even those that ean be pitchased without « prescription, if used impropeily can case injury. However, high-alete medications cause hnzm gliteis ikely to be moze serious when they aze given in exxor, which eda ead to incseaseel patient suffeting and pocentiallp addition h cating for these heightened bo? easing siguil ‘when chey ate used hough mistakes may or may costs associated wit bbe more commoniwith these drugs, the consequanées of an excor are cleasls more devastating to patie most ficquently citedexamples of hightalert medications include insulin, opioids, chemothezapeutic agents, om aga b medications with a nanow therapent tc 2 digoria), nensomusenlar blocking ageats, aad epicial oc intetaecal medications, ccent bes oti M < fc here minibag of compatible solusion ane uot in a singe. A significant adverse event resulting in severe newological damage and often death, has occussed from che inad \dministzation of vinea alkaloids via che intzatheeal route, In organizations ia which vinea alkaloids are dispensed in a minibag, there have been no reported cases of uted by The Joint the Oncol accidental administration ofa vinca alksloid by te intathecsl soute, This best pisctice is che World Health Organization, the A Society of Clinical Oncoloes Nnssing Society (ONS), aad the National Compeeheasive Cancer Networks Examples of lists of high-alext medications ate available fkom organizations such as ISMP and the Organization (WHO).* For safe management, the hospital needs to develop its own lists) of high medications bared on its unique utilizstion pattezns of medications and its own intemal data sbot ear misses, World Health CONFIDENTIAL DO NOT COPY - DO NOT DISTRIBUTE{©2019 Joint Commission International CT Stundasde for Hoopsale Drsit ‘ch Ed Revsiont ISG3-PSG.32 medication exrors, and seatinel events, as well as known safety issues published in professional Iteratuse, (iv ser MMU.7.1 and QPS.7) The list includes medications identified as high sis for adverse outcomes. Information from the litesstise aad /ox Ministoy of Health may also be usefil in helping to identity which medications shold be jcluded.'6"” A list of high-slest medications must be up-to-date, knowa by clinical staff, and accompanied by tobe applicable in vations settings and sustainable over time, Many of these stustegies should also be considesed forse with other medications. Examples of stategics may include: (¢ Standadizing processes associated with ordesing, stozace, prepaiation, and administuation of these medications Impeoving access to infocmation about there daugs ‘Limiting access to higl-alest medications sing additional labels and automated alests Appling sedundanciee Locivalke, sstadvalise (LAS) names ace medicine aaites that look a: sot the sate 2¢ other medicine names ‘chica waitiea or epolien, Loolalike medicine packacing sefess to medicine coutaiaess oF Pimsar packaviae that looks lke that of anothex medicine. Medications at ssk for 6k aike/sound-alike confusiony ox simslax product packaging, may lead 0 poteatially haamfel medication eros. These afe may medication names chat :oxad oz look like other medication names, for example dopamine and debttagsiac. Confusing names is « common cause of medication exxors throughout the world. Coataibating to this confision axe + incomplete knowledge of drug names: + newly avalable products: + similar packaging or labeling; + Siar elnieal usefand + legible prescriptions os misindéscancing fusing faning of veshallesdess Hospitals need to institute reunansgement steategies © minimize advecte events with LASA medications and sobauce patient safety A frequeniy\Gted mediéation safety Bane is the ineSirect or talntentional administration of concenteated clectolytes (for example, potassium ebléide, potassium phosphate, sodium cioride, and magnesium sulfate) dentit f si of the inact ation of, concentrated electolyre in ite comeentsated foam, The most effective means to reduce os to eliminate these occuneuces is todevelop a process for managing eoncentuated electrolytes that includes semoving the concentrated electBlyres from the patient care units to the phasmacy. Vials of coucentated foums of clecuolyte: that sequize dition befaze IV administation showd not be available as ait stock on any patient ence wnite 4 Ha tosk) to-paticat ida pate sto this © d snugecy Kit or a cardiac surgery lodked storage acea ancl magaesitim sulfate contsined in emergency cacts of in aceat ‘inshich paticats with pre-eclampsia may be treated Gc. Jabor and delivesy. emesgency department, ot intensive case uni. Whesexer concentrated electrolytes are stored, they are cleauy labeled with appropsiate wamings (ce, CONCENTRATED clectsolite — Dilute befoie administration) and seasegated fiom other medications, Ouls valified iid e Administration of electrolyte replacement therapy for hypokalemia, hypoaateemia, and hypophosphatemia is best pafonmed using standaudized guidelines and/or protocols which do not involve dispensing ox handling CONFIDENTIAL DO NOT COPY - DO NOT DISTRIBUTE{©2019 Joint Commission International CT Stundasde for Hoopsale Drsit ‘ch Ed Revsiont ISG3-PSG.32 Measurable Elements of IPSG.3 DL. The hospital identities in writing its lst of high-alert medications, D2 The hospital develops and implements a process for seducing the risk and haem of high-slec that is vwaifoem thoughout the hospital, D3. Thehospital anally ceviews and, as necessary revises its list of high-aleet medications. Measurable Elements of IPSG.3.1 OL. Thehospital idcuitics ia waiting its lst of lookalike /sound-alise medications 2 Thehospital develops and implements a process for managing look-alike /sound-alike medications that is ‘uaigoum thoughout the hospital 3. Thehospital ows and, cy_ revised its list of look-alike/sound-alike medica Measurable Elements of IPSG.3.2 DL Thehospital does nos stace vials of conceatested electiolytes outside of the plasmacy except in the situations identified in the intent, 2 Only qualified and trained individuals have access to concentuated electwolytes, and they axe cleasly labeled with appcopsiate waminge and cegsegated fiom ates medications 3. Standard protocols are followed fe sdistric, aad/or neonatal electrolyte seplaccanent therapy to : ' angbhypophosphatcmia, CONFIDENTIAL DO NOT COPY - DO NOT DISTRIBUTE{©2019 Joint Commission Internationa CU Stade fox Hoopsale Drsit ‘ch Ed Revisione TSG IPSG.5.1 International Patient Safety Goals (IPSG) Standards, Intents, and Measurable Elements Goal 5: Reduce the Risk of Health Care-Associated Infections Standard IPSG.5 ‘The hospital adopts and implement associated infections. ® widence-bared han Standard IPSG.5.1 Hospital leadoas i : etventions to improve patient outcomes and redube the risk af inspicsl-ascociared infections. © Intent of IPSG.5 and IPSG.5.1 Infection peevention and canteol are challediging ia most health case settings, and csing sates of health ease associated infections are a m#jof concer fox patients and health care practitioners. Infections common to all health ease settings include cachetebasseiated iinasy tract infections, bloodstceam infections, and pneumonia often associated with mechanical veatilstion Cental to the elimination of chese and otfits infections is prOpes hand hygiene. Evidence-based hand-hygiene guidelines age available from the Wosld Health O:ganization (WHO), the United States Centers for Disease Control and Prevention (US CDC), and varions étler national and international organizations. ‘The hospital adopts and implements curteat evidence-based land-bygieue guidelines, Hand-Liygiene guidelines are posted in appropriate azeas, and staif axe educated in proper hand-washing and hand-disinfection proceduces, Soap, disinfectants, and towels cx other means of deping ase lncated i thote aseas where hand-waehing and hand disinfecting proceduses aze sequited, Some patient ease teeataients and interventions have bees identified ae majoc sousces of hoepitalassociated infections: such a: suspical proceduses, mechanical ventilation and ineestion of central lines or indwelling catheters Hospital-associated infections can severely impact a patient's emotional and financial well-being. They are a Significant sousce of complications that caa lead to fiscther illness and even death, Many of these infections are preventable, Reseach studies supgest that implementing practices designed to prevent hospital-acquised infections ‘can Jead to as much as a 70 percent sednetion of those infections Tn 2001. she Institute fox Healthcare Improvement (IHD began developing and testing a concept of enhancing work and communica ultidisciplinaxy er to improve the clinical wided co parient This initiative led co th “bundles” of case, Bundles are defined by the [HL as: “A small set of evidence= based interventions for a defined patient segment/ population and caie setting that, when implemented togethe, CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit ‘ch Ed Rensiont TSG IPSG.5.1 ‘will xesult in sionificantly better outcomes shan when implemented individually.” Examples of bundles include: ‘central ne-associated bloodstseam infection (CLABSD), ventilator-associated pneumonia (VAP), eatheter- sis bundle, sociated usinary tract infections (CAUTD, suspical site infection (SSD and severe Implementing bundles of caze will have the greatest impact on patient outcomes when the hospital identifies gaps in best practice o¢ continued poor outcomes in a particnlar area, Evidence-based infection prevention bundles have been shown to have a greater impact on seducing the tis of infection than wien individual improvement stuategies are implemented sepasately. I is impostant fos leaders to evaluate comphance with the bundles and tracks Impsovements in clinical outcomes, Measurable Elements of IPSG.5 DL. The hospital has adopted cuszeut evidence-based hand-hypiene guidelines. 2 Thehospita implements a hand-ygiene program throughout che hospital a ‘Hand-washing and linad-disinfection procedvses ase uted in accordance with laud-hygiene guidelines tyoughout the hospital Measurable Elements of IPSG.5.1 1 Hospital leaders identify pdodiy areas for improvement of hospitalacquised infections D3. Evidence-based incerventions used to.zeduce the tsk of health caze-associated infections axe evaluated by bhealthease practitioners for compliance and improvement in clisical onteames. CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internationa CU Stade fox Hoopsale Draft "ch Ed Revisit PCC Chaptex Patient-Centered Care (PCC) Standards, Intents, and Measurable Elements Standard PCC.1 ‘The hospital i sespousible for providing processes that suppost patients’ and families sights ducing care, Intent of PCC.1 ‘The hospital leadership is primaily responsible for how a Isnow and to tiadesstaad patieat aad regulations. Leadership then provides direction to depastment/sexvice leaders who ensuse that staff throughout the hospital assume responsibility for protecting these sights. To effectively protect and to advance patient sights, leadec nasbilties in elation to the eomamaity seared by the haepital hospital Will trea is patients. Thus, leadesship needs to in laws aad ily sights and the hospital's sespaacibilties a8 identifi hip wacks and seeks ta adlecstand theie eos en. the patient wishes to have family patticipaze in their care decisions: however she may define tamil diffexently Hom the tzaditional definition of family. The patient has the sight to i 10 they consider to be their family and be allowed eo have them involved in theic care. Tp osdes fos fhailiee to pactcipate, they aust be allowed to be piesent, When capable, the patient is given the opportunity to decide if and to what extent they wish family to be involved, what information seguding theix eaze would be provided to family or others, and under ‘har cieeumetances, For example, the patieat may aot wieh ta have a diagnosis eased with family, oe the family may not want the patient to know his ot her diagnosis, Patient and fly sights ace « fondamental clement of all contacts among « hospital, is staff, and patients and families, The hospital develops and implements processes to ensure that all stalf members are aware of and respond to patient aid family rights issues when they interact with and cae for patients thyoughour the hospital The hospital uses a collabacative and lnchnsive process to develon the policies and psocediases and inchtdes patients P P P and fauniies in the process) Measurable Elements of PCC.1 D1. Hospital leadership works collaboratively to protect and to advance patient snd family sights D2 Hospital eadesship implements patient and family sights as identified in lnws and eegulations D3. Hospital leadership proteers patient and family sights in xelation to the cultural practices comity or indivicual patients served. 4. Hospital easessh th Jat to identify who they wish to pastisipate in shs decisions, 5. Thehospital has a pro the patient's faurily's puetecence in deteimining wit information tezncing their care would be provided to family of CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex others, and under what circumstances GO 6. Altbealth r ‘uained on th for and theit tol ag paticatand family hts and pasticipation in care. Standard PCC.1.1 “The hoepital seeks to seduce physical, Inngwage, eulmacal, acl other bassiess to access aad delivesy of secrices and ssovides infomation and echcation to patients aa smilies ia a lagu nance they can wadssstaad. Intent of PCC.1.1 dani tient to a hospital os egisuation as an outpatient for sample. cc emergency depastmicat smblatory clinic) con be fi ‘nd confusing for patieuts, Horpitals Freuentysexve commnites with a diverse population, Pasenrs may be aged, have disabilities, speak moltple langage or dialeess, be culeaally diverse, oe posses otnesbassies that make the process of accessing and ceceiving ene vey difficult. For example, tients with impaised mobility or who ase visually impaized may have difficulty enteting-or nsvignting the hoepital : st ait sl smiay not be able to uindesetand all aspects of tele cace and teeatment Patients aay fad is complicated aad Sonfusine when attempting to access case aiid undesstond theistights and sesponsibiities ia the ctse piocess Te hospi siete baes,mplameted eas vin oo eu basis an sean sa seduce the impact of bassiess for patients seckingare, saft accessibility to bulding ‘ce ses pats ies alps ligase sinha hes af smullingal signs and/or ingesnationalermbole, and tanslatoss may Be.ised foe patients «peaking different lauguages, ‘The hospital prepares a wsitten statement of patient and family sights and sespousibilities daat is available to faelity ov avallable as a beoclvuse. The statement ie appropriate to the patient's age, uadecetandiag, and language, When saitten communication is aot effective of a ‘he paticat and funily ie infosmed of cheis siehts rs 8% w Measurable Elements of PCC.1.1 1. Thedepartment/service leaders and staff Of the hospital identify theic patient population's most ‘common aud cholleneing bansiess to accessing snd seceiviag car. 2 The department/service leaders develop and implement a process to overcome or limit bassiess to access so-csis and their impact on service delivery for patients seeking care as a z a . a language the patienr waderetands 4 Information about paticat sights and cespoasiilties is provided to each patient in writing or other rmcthod in a language the patient understands 5. Thesttement of patient sights and sesponsibilities is posted or othenwise available feom staff at all times CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex Standard PCC.1.2 The hospital provides case that suppocts patient digaity, is eespectful of the patient's personal values and belief, and sespouds to sequests for spistual and zeligious observance. Intent of PCC.1.2 (One of the most important human needs is the desite for sespect and dlignity. Often, patients expesience feelings floss die to increased depeadeacy in sitions atch as the aed for assietaace with feeding, meremeat, and ‘personal hygiene. The patient bas the zight to care that is respeetfl and cosisiderate 2 all times, in all cixcumstances, and recognizes the patient's pessonal worth and selédigaity.4* Esch patient brings his or her own set of valves and beliefs to the cate process, Stzougly held values sud beliefs ccan shape the cate process and how patients respond to caxe. Some values and beliefs axe commonly held by all patients and ace feeqjtently culm and seligios ia ocigin. Other valtes and beliefs ace those of the patient alone. All patients aze encouraged to express theis belicts in ways that respect the beliefs of othevs. Staif sesk 12 a cy provide w . 's values and belie When a patient of family wishes to speak with someone related to religious or spiritual needs or observe a spisital or seligions custom, the hospital has a process to xespond to the request. The process may be earsied our through on-site celigions staff, local sources, or family-refeesed sousces. The process 29 respond is more complex: for example, wlieu the horpitel o: countyy does not officially “recognize” and/or have sources zelated to a religion o belief for which there may be a request. Measurable Elements of PCC.1.2 powide case thats sepectfil and eohsidecate of the patient's dignity and celfwvorth. O22 « ad D3. The hospital sesponds to routine as well as comple cequests related to zeigious ox spixinual support. Standard PCC.1.3 ‘The hospital establishes a process to ensure patient privacy and confidentiality of care and information and allows sents the tight to have access to cher health information within the context of existing law and culna Intent of PCC.1.3 Patient privacy, particularly during clinial interviews, examinations, procedures /treatments, and transport, is important, Patients may desite privacy fiom other staff, from other patients, and even from family members or other designees identified by the patient. Also, patients may aot wish to be photographed, to be recorded, or to participate in accreditation survey interviews. Although there are some common approaches to providing privacy for all patients, individual patients may have diffesent or additional privacy espectations and needs according to the ination, and these expectations and needs may chaage aver time. Thus, a¢ staf¥ members provide ease and services to patients, they inquire about the patient's privacy needs ancl expectations related to the eare or service. This communication between a staif member and his or hes patient builds trust and open communication and may be documented in the patients plan of case, pasticulacy wea the patient expcesses diffeceat o¢ additional peivacy expectatios Medical and other health information, when documented and collected, is important for undesstanding the patient and his or her needs and for providing care and sesvices over time. This information may be in paper or electzonic CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex foun or a combination of the two. The hospital respects such information as confidential and his implemented policies and proceduses that protect such information from loss ox misuse. The policies and proceduses sefleet lnfocmation that is celeased as sequised by laws and sezulations Statf respects patient privacy and coyfentaiiy by not posting confidential information on the patient's door or at the nussing station and by aot holding patieat-selated diseustioas in public places. Sta ace awase of laws and regulations goveming pavacy and the confidentiality of information, Patients are also infosmed about when and undes what cisetimstances infasmation may be celeated aad how their pesimissioa will be obtained, Inddition to granting peumission to shass health information with othess, paticnts also bass she sight i access icc ow heath information, When patients have access to shcic health infoumsation i euables them 10 have th information they used to make beter decisions about thes heathesie dinaidiion, access to health information allows patents to seview and monitor compliance with thes ueatment plans fx any exoss chat may be in she ‘onfidentiality of information and inform patients about how the hospital respects theiz health cord, and monitor their progeess in managing theic diseate(#), among other benefice, 7 s silat thheough a secuce website, such as a patient postal, The hospital has a process foe psowiding patients mith access 10 theix health infomation within the contest of existing lawsacgulations, and cultuse, Measurable Elements of PCC.1.3 1. Staifmembess meet patient expectations and nceds for plivaey, when exps ssed, ding case and 2 A patienr’s expressed need for priva [peocedces/seestanent, and teaaspoct is xespected for all clinical interviews, examinations, D3. Confidentiality of patient information is maintained according to laws and cegulatioas. D4. Thehospital as a process for patients to grant pesmission for the felease of information not covered by laws and cegulations 5. Thehospital bas a process for providing patients with access to theis health jnfosmation within the ‘contest of existing laws, segulations. and enlace. 6. Access to health infetmation is timely and costdoss not prevent access to this information for the Pumpose of maintaining eonsinnity of cate, Standard PCC.1.4 ‘The hospital rakes measuces to prOteet patients’ possessions from theft of loss Intent of PCC.1.4 The hospital communicates its responsibility if any, for the patient's possessions to patients and families. When the hospital takes sesponsibility for any or all of the patient's personal possessions brought into the hospital, these isa process to account for the possessions and to ensute that they Will not he lost or stolen. This process considers the possessions of emergency patiests, same-day suegesy patients, inpatienss, those patients taable to make altesuative safekeeping arrangements, and those incapable of making decisions seguding their possessions. Measurable Elements of PCC.1.4 1 The hospital has decesmined its level of esponsibility for patients’ possessions CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex 2 Patients receive information about the hospital's responsibility for protecting personal belongings. 3. Patients’ possessions ate safeguacdled when the hospital assumes responsibility or when che patient is ‘unable to assume responsibility Standard PCC.1.5 Patients ace peotected from physical asamul, and populations at sek ace identified and peotected from additional vvulaceablites Intent of PCC.1.5 The hospital is sesponsible for protecting patients fiom physical assault by visitoss, other patients, and staff. This responsibilty is particularly relevant to infants and children, the elde:ly, and others unable to protect themselves or to signal for help. The hospital secks to prevent assault thsough such processes as investigating individuals in the freliy without identification, monitoring semote or isolated acess of the fail, and quickly sesponcing to those thought to be in danger of assault Each hospital identifies its atsisk patient groups (such as childcen, disabled individuals, the elderly) and establishes ppeocesses to protect the sigts of individnals in these asoups, Vulnerable patient aronsps ancl the hospitals sexpousibility may be identified in laws and aegulations, Staif members waderstaad their zesponsibilties in these processes, Childven, disabled individuals, the eldedgyand other identified populations at sisk are protected. Comatose patients aad individuals with mental ox emotioinal disabilities are also inckided. Such protection extends beyond physical assault to other areas of safer, stich as abusBuegiigent care, withholding of services, ox providing assistance in the event of a fixes Measurable Elements of PCC.1.5 D1. The hospital develops and implements a process te protect all patients from assault D2 Vuherable populations thar axé at additional sis ate identiied. D3. The hospital develops aud implements a process to protect vulnesable populations fiom other safery D4. Remore or isolated ateas of the fallity axe monitored, Standard PCC.2 Patients and families axe engaged én all aspects of their medical case and tweatment though education and participation in cace and treatment decisions and care processes. ®) Intent of PCC.2 Patients and families become engaged in their healthcare process by making decisions about care, asking questions about case, requesting a second opinion, and even refusing diagnostic procedures and treatments, For patients and families to paiticipate in ease decisions, they need basic infomation shout the medieal enadlitione found chciag assessment, including aay confismed diagnosis, aud the propored case and treatmeat, Educatiou is planned to aie that every patient and when applicable, che patient's family, are offexed the education sequited to be able to participate in their care decisions and ensure they are able to care fos themselves aftee discharge. By engaging with patients ia the decision-making process, patients and bealtheare providess can collaboratively make bettes decisions CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex scguiding the paticnt’s Leal that can Jead to improved patient outcomes Duscing the eace process patients have a sight tobe told of the expected outcomes of the planed ease and tucatment, In addition, when an usanticipated event or outcome has occuuzed dung thei caue o: treatment, i is important that they also be informed of that event. Unanticipated events may include hospitalcacquised infections, presse ulcess,o1 post-opetative infections, Patents and families understand that chey lave a tight ro this information and who is responsible for telling them. For patients, it should be clear who wll provide them with the information abort theis medical condition, eae, treatment, ottcomes, unanticipated events, and the Like Patients and families undesstand the type of decisions that must be made about care and low to pasticipate i those decisions. Although some patients may not wish to pessonally know a confirmed diagnosis ot to pasticipate in the decisions cegaeding theic eaze, they are given the opportunity and éxa choose to pasticipate through a family member, fiend, or a surrogate decision maker When a patient cequests a second opinion, iti expected thatthe haepital will not prohibit, peevent, or abetniet a patient who is seeking a second opinion, but thes, the hospital will feltste the second opinion by providing the patient with information about his or her condition, such as test results, diagnosis, recommendations for treatment, tnd the like. The lepital anast not withhold this infosmation if « patient cequeet it for a second opinion. The hospital ie not expected to provide and pay for a second opistion whien sequested by the patient. Policies addcess the patient’ sight to seek a second opinion without fear of compromise to his or her care within or outside the hospital The hospital supports and promotes patieat aid family involvement in all aspects of cate, All staff’ members axe teslned on the policies and poncedinces acl on tele sole in supporting patient’ anc fhanliee’ sights to pactcipate ia the caze process, Measurable Elements of PCC.2 DL. Thehospital supposts and promotes pasientland fadilly engagement through pasticipation ia care [pencestes aad in decision making to the exteat sep wich, Participation in the eae process includes educating paticats and family about sheis medical conditions, any confitmed diagnosis} and the planued cae and tieatment(s), 3. Patients are informed about the expected Gitcomes of care and teeatment. 4.0 Patients are told of any unantieiBated outcomes thit mar have occuned dusing the course of their caze rnd treatment. D5. Thehospital facilitates a patient's requestp seek a second opinion without fear of compromise to his ox Standard PCC.2.1 The hospital infouns patients and families about their tights and responsibilities to zefuse or discontinue treatment, ‘withhold resuscitative services, and forgo or withdeaw life-sustaining treatments. ® Intent of PCC.2.1 Patients, or those making decisions on their behalf, may decitle not to proceed with the planned care or treatment or to discontinue case of treatment after i has been initiaced, Some of the most difficult decisions selated 10 sefuasiag oc withdeawing ence a decisions about withholding cesecitative services o¢ Fosgoing o¢ ‘withdawing life-sustaining treatment. These decisions are difficult not only for patients and families, but for health cece practitioners and che hospital as well. No single process can anticipate all the situations in which such lates CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex decisions must be made. For this xeasou, it is important for the hospital to develop a fiamework for making these difficult decisions, The frameworks + helps the hospital ideatify its position on these issues; + casuues that the hospital's position conforms to its community's sligious aud evltusal acts and to aay legal or segulatory requizements, paticulaely when legal zequisements for resuscitation are not consistent swith the patient's wishes: + addzesses situations in which these decisions are modified dosing cate; and + ghides health case practitioners through the etsieal and legal iemtes ia easrying out sacha patient wishes. To ensue that the decision-making process selated to cnusyiig out the patient's wishes is applied consistently, the hospital develops policies and proceduses though a process that includes many professionals and viewpoints. The policies and poncedinces ideatity lines of accomntability and seeponsibiity and how the peocess is documented in the patient's medical zecord. The hospital informs patients and families about thele tights to atake these decisions, che potential outcomes of these decisions, and the hospital’s responsibilities related to such decisions. Patieats and families about any ease and tveatment alternatives © informed Measurable Elements of PCC.2.1 1. The hospital has identified its position on withholding resuscitasive secvices aad forgoing or withderwiag life-sustaining treatments 2 Thehospita’s position confosms to its commmunity’s seigigus and cultural norms and any legal ox segulatory requitements D3. The hospital informs patients and families about their sights 0 sefuse or to discontinue treatment and ‘the hospitals seepoasibilities elated to such decisions D4. The hospital infosins patients about the consequences of their decisions ‘The hospital informs patients about available enze and treatment alterna 1 6. The hospital guides health case practitioners on the ethical and legal considerations in cacsying out paticat wishes segazding treatmeat alternatives Standard PCC.2.2 ‘The hospital suppoui@the patient's ight to assessment aud mansgement of pain and zespectfil compassionate care ar the end of lite Intent of PCC.2.2 Pain is a common past of the patient expesience, and uncelieved pain has adveese physical and psychological fects, A patient's response to pain is frequently within the coutext of societal aoums and cultural sud seligions tuaditions. Thus, patients are encouraged and supported in their reporting of pain. Dying patients have unique needs that may also be influenced by cultusal and religious traditions. Concesn for the ‘patient's comfort and dignity guides all aspects of ease doting the final stages of life. To accomplish this, all sta smiembaecs ace mace awace of patieate' taique needs atthe end of Hie. These seeds inchide teeatment of primary anc ondary gurptons, pain management; response to the patient's and family’s psychological, social, emotional, religious, and cultusal concems; and involvement in care decisions. The hospital's eaxe processes zecognize and zefleet the sight of all patents to assessment and management of pain and atsessiment aad management of « patient's nique aced at the end of life CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Intemational CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex Measurable Elements of PCC.2.2 1 L. The hospital cespects and supports the patient's ight to assessment and management of pain. D2 The hospital cespects and supports the patient's right to assessment and management of the dying: paticut’s needs, 3. Thehospital’s staff undesstand the personal, culnaeal, and societal influences on the patient's experiences swith pain 4. The hospital's staff undesstand the personal, eultusal, and societal influences on the patient’ experiences sith death and dying Standard PCC.3 The hospital measures, analyzes, and—swhea necessacy-—imipeores the patient expecieace in cxces to enlssace the spuality-2f patisut.sais, Intent of PCC.3 5 nises other professionals. and ancillary staff as wellas dh nt and services th ws using their healtheare encounters, An important component of patieat-centeced care is uaderstanding the patient sspsuioas. Gathering and analyzing information about the patient expetieliéecan be used to help identify ifthe care patients sus cessising is sesponsivs io the individual paticnt piefcxcusessmesdaad values, Evaluating the paticut infomation about che qualite of paticat page. ‘The hospital lise establidhed « plocess ff collecting aud anshzine the patient expeticace os past of measwing the ‘quality of patient eaxe and potentially improving patient outcomes. Measurable Elements of PC! 1 Tendesship determines 3 peiosisyatea for improving the patient experience which will positively impact ‘patient esis D2. Leadership develops and implements a prbcess for assessing the patient experience and its impact on ‘patient cate [1_3. Dats from the patient experience is ageresnted, analyzed and transformed into information to identify steategies for improving the patient experience, (D_4 Idenritied strategies fox improving the patient experience ate implemented, a Impsovements to the patient experieace ave analyzed and sevised in odes to optimize thele impact on quality of paticnt cass, Standard PCC.3.1 The hospital informs patients and families about its process to seceive ancl to act on complaints, confers, and differences of opinion about patient care and the patient’s right to participate in these processes. @® CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Intemational CU Stade fox Hoopsale Drsit "ch Ed Revsiont PCC Chaptex Intent of PCC.3.1 Patients have a sight to voice complaints about their eaxe and to have those complaints reviewed and, when possible, eesalved. Also, decisions segaeding care sometimes present questions, conflicts, or other dilemmas for the hospital and the patient, family, or other decision makers. These dilemmas may atise from issues of access, testment, or dischaage. They can be patticulasly difficult to resolve when the issues involve, for example, ‘withholding sesuscitative cecvices o¢ foegoing o¢ withdenting life-sustaining teestment The hospital has established processes for seeking resolution of such dilemmas and complaints, The hospital Identifies in policies and peocediaces those who need ta be involved in the processes and how the patieat and family participate Measurable Elements of PCC.3.1 1. Patients axe informed abour the process for voicing complaints, conflicts, and differences of opinion GF 2 Complaints, conilicts, aad differences of opinion are investigated by the hospital. 5. Complaints, conilicts, and differences of opinion chatarise during the care process are resolved, a 4. Patients and families participate in the resolution peacess, Patient Consent Process Standard PCC.4 General consent for treatment if obtatied when a pati igamitied a8'an inpatient o: is segisteved fox the first time as an outpatient, is eleas in its scope ad Lis. ®) Intent of PCC.4 Many lospitals obtain a genczal code (thet ina In addition sesistaneellind she growth of super-buBejthese aiBoften side effects and/or complications to antibioué treatment, inchidingeaequisiie Olsndiury finch . ‘ emeigeucy drug box/ say on the neouatal/ pediatsie emergency cout with medications and concentsations sat ue appropiate for neouates aud match applicable protocols and dosing guidelines Measurable Elements of MMU.3.1 1. Emeigeney medications axe immediately available in the units Whese they will be needed or axe seni accessible withia the hospital to meet emesgency need 2 The hospital establis@ilad implements process for how emeigenepimedications are unifoumly stored, maintained, xepldced when used, damaged, of out of date, and piotected from loss or theft D3. Access ro emergency medications dacs not sequice a spefic individual or keys to unlock the emexgencs sai, 4. Emeagenep siedications ase monitoced and seplaced in « tntely maanes after use os wien expised or damaged. 5. (Thee hospital uses a 8k: based approach in identiffing and implementing strategies to improve the ‘efficiency and accuracy ef medication administistion dung emergency resuscitation Standard MMU.3.2 The hospital has a medication weal system. Intent of MMU.3.2 A miedication cecal] ocewss whes a dig is cemoved from the macket because ite Fouad to he either defective o potentially hnumfil, Defects to a medication may be selated to incossect packaging, potential contamination, or fact alt npuitis a strength potency. Som 1h the dig will identify a problem with their deus and voluntarily cecll it Otlies times, a government agency will request that the ‘medicine be recalled alter seceiving sepoxts of problems fiom the public, Communications of medication recalls lsectly fiom the manufsettzes os fiom segrlatony authorities, Hospitale amet easuse they have a process for receiving notifications of medication recalls and for identifying, retieving, and renumning, or safely and properly destroying, medications recalled by the mannfaesuter or supplier. The recall process includes any CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees medications compounded within the hospital in which products that have been recalled have been used. There is a policy or proceduce that addcesses say use of ar the destruction of medications known to be expised or outdated, An expiced medication is oue that is past the expizy date listed on the original packaging from the ‘manuifactuses. An outdated medication is one that is opened and is typically safe and effective to use For a shoxt petiod of time after opening (shelf life). These outdated medications shotld be mazked with a date of expiry based fon when they were opened so that staff know the end date of use Measurable Elements of MMU.3.2 QL The shes and. iving and fications of medication 2 The process includes identifying, retrieving, and setuming of safely and properly destroying, medications ‘ccalled by the manufacruee, supplies, ar cegulatocy agency. as ss includes m s snded si which produes bens secalled have been weed. 4. The hospital establishes and implements a piSeess for managing unopened, Bxpited, or outdated medications 5. The hospital establishes and implements process fiche deatitetion of medicaiofieiowa to be expired or ovsdaced. Ordering and Transcribing Standard MMU.4 Te borpital identifies anc dosinents a ouktent list of meditations taken by the paticat at home aud view i ss medi i ® Intent of MMU.4 he sisks for adverse events. Patients enteving 2 hospital ace often taking multiple medications at home and may bs atuish ofan adverse event ifn accusate list of those medication is not documented in the patient's secouc, Medication disexepan Jeet patient ouseomes. [kcan be difficult a ob plese list rom eve patient in an encounter, and aceusacy is dependent on the patient's ability and willingness to peovide this infomation. A csedible effort to collect this infoummation is secogaized as mesting the intent of de sequice 2b is i a and/ ‘with the patient's peimacy pliician, D 5 infoxmasion that cl 7" ncile medications include, but Jimited to, medi same, dose, feequeacy, coute, and pucpose, Orgenizations should identify the infosmation that needs to be sollested to reconcile cussent and newly cadsued medications and to safely pressuloe medications in the fase, rod medical includ sw of ced new medication against the lst of medications th patientis cuentis taking, The goal of cis review isto impiove the quality and safery of adding a new medication o the patient's treatment plan and reduce che disk of an adverse medication event, A listing of all earcent ‘medications is recorded in the patient’s medical record and is available to the phammacy, arses, and physicians. “The hospital establishes a process to compate the patients list of medications taken prior to admission against the CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internationa CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees initial orders. Measurable Elements of MMU.4 1. The hospital idenities the information needed to reconcile current and newly oxdesed medications a “The patient's medical records contain a list of current medications taken prior to admission or registration 9s an ourpatient, and shis information is made available to the patients healt care ppatetitioness and the pharmacy as acededl 3. Initial medication orders aze compared to the list of medications taken prior to admission, accouding to the hospital's established process. Standard MMU.4.1 The hospital identities those qualified individuals pesmitied to presesibe ox to ordeBamedications. Intent of MMU.4.1 Selecting a medication to teeat a patient cequises epecitic knattledge andl experience. Each hespital is ceepoasible for identifying thore individuals with the requisite hnowledze auhexpefieace and who are slso permitted by census, certification, laws, or zegulations to presexibe os to order gnedieations. A hospital may-place limits on peescsibing o¢ osdesing by an indivicial, atch af fog eaatsolled substances, chemotherapy ageats, or sadionctive and investigational medications. Individuals petted t@lpsescuibe and twlorder medicatious ase knowa to the phasmaceutical service or others who dispense medications, Eemexgenc? stations, the hospital identifies any Additional indivichuals pesmitted te presesibe or to oles mediation, Measurable Elements of MMU.4.1 1. Only those penned by the hOspital and by Helevast licensure, laws, and regulations preseul medications. 2 ThetlBtes:ablishes aBaiimplemeni@p:ocess ta)place limits, when appropriate, on the prescxibing ot oxdesine practices of individuals 3. Individuals permitted Bo prescsdbBland to order medications axe known to the pharmaceutical serviee and ‘others who dispense medications. Standard MMU.4.2 “The hoepital identities cafe presetibing, osdesing, and teantesibing pesctices and defines the elements of a complete order or prescription. D Intent of MMU.4.2 ‘A common cause of adverse events in the hospital seting are medication exxors, “Medication erxors are most common at the ordering oc psesesing stage, Typical eqtacs include the healthease peovicec waiting the wong medication, wrong zoute or dose, or the wrong frequency. These ordesing ezors account for almost 50% of cat Tn ds, illegible medica ns of ovlcrs atc one cause of medic cuors that jeopardize patient safety and may delay treatment, Stategies to reduce illegibility of waitten orders axe important in reducing the sisk of medication exoss. Safe presczibing, oxcesing, and wanscuibing axe guided by hospital policies and procedures. Medical, aucsing. pharmacy, and ad tive staff collaboxate to develop and CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees to monitor the policies and proceduses, Relevant staff ae tained in comect prescribing, ordering, and tanscribing pnetices To reduce the variation and improve patient safety, the hospital defines the requited elements of a complete oxder or prescription. Alloxdess and prescriptions contain the name of she dave, she dose, and the frequency and route ofadministration, Also, the following additional elements are included in the prescription and order whea appropriate 2) The data necesency to accucately ideutify the patient bb) When genetic or braud names are acceptable or required (©) Specific guidelines for the use of PRN (pro se ntva, o: “as needed”) oxders that include indications for suse and detailed dicections for aveclapping ordess, such a¢ mase than one medication foe pals 1g) The types of orders that sue weight bared or otherwise adjsted, suck as for childuea,fsal eldely, and oncology patients 2) The mpes of orders that ace adjusted for theespeutielfaage 8) Rates of administration when intsavenous infusions are oxdezed 2) Other special oxders such as titrating, tapeting, ox range oxdexs There are processes in place to manage + medication orders that are ineomplete, illegible, or unclear; + precantione foe osdeting medications with loakealke oc soatideliie names + special types of oxdess, such apemergency, standinghoriiutomatic stop, and any elements unique to such orders: and + verbal, telephone, and text medication ditess and the proedis to verify such oxders (scored at IPSG2, MEBs | and 2), Thus, this standard sets hospitahwide expectations for medication orders. The Processes ase reflected in complete orders entered in the medical record the pharmacy or dispensing unit veceiving the information needed for dispensing, and the admnisteation of the medication based on a complete Oxdet Measurable Elements of MMU.4.2 1. The hospital establishes, implements, and trains staff on a process for the safe peesceibing, ovdesing, and uatisesibing GF medications in the hospital, “All oxdecs and preséliptions contain the name of the dug, the dose, the frequency and route of administeation, the indiéation for prescribing the medication, and the maximmam dase 3. Addldnat elements of complete medichtion oxdess ox prescriptions inchnde atleast) through g) Identified i the iateat 26 appiopsiat to the ordes 4. Thehospitalderelops and impleasens a process ro manage medication ccdess that ace incomplete, ‘legible, or ele; including messes to pusvent continued occuszence. “The hospital develapiandimplemears a pcocess to manage special ypes of osders, ech as emesgeney, standing and automatic stop, ad any clements uaique to such ordess ae M b a ov patient's aredical cecoud at discharge or ancien CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees Preparing and Dispensing Standard MMU.5 Medications aze prepased and dispensed in a safe sud clean envionment, Intent of MMU.5 The pharmacy or pharmaceutial sexvice and others with proper tning alexpesicnce prepase and dispense medications in a clean and tafe envizonment that complies with laws, segulaslons, aad professional pesetice standauds, The hospital identifies the standauds of practice for a safe/and elean prepaation and dispensing environment?“ For example, standasds of practice can includethowmedieation preparation areas are to be cleaned and when a mati should be wons, o° a lamina: sieflowe hood should betased in the peepacation of a medication. Some medications and solutions seqbits paspadiiog wadss cory spec euilslines: for example, mponnded steile products such as chemothesapy. total parcntcsal nutition TPNDand cpidusals. Staff compounding medications ace trined in the principles af medication pzepacation and ateptic technique, Sinilacy, for example, sisiile compounding). imation in medication preparation tha c of ntagions diseases is the use of Single-use and auiltidose vials on mace than ane patie, The misuse of these vials has caused harm to individual stancaeds of safe practices foe the Webof single-dose and multidose tials, for example, suuinges atc siucle paticniiiaes only and abyss -coicsine aadabspith wesucedle os used ssuings, Medications stoced and dispested fom afeas outside the phacmacy (for example, patient care units) comply with the same safety and cleanliness measwies, Measurable Elements of MMU.5 1. Medication preparation and dlsptusing adhese to Btvs, segulations, and professional standasds of panctice D2 Mediestions are prepared anil dispensedlin clean, uncluttered, safe and functionally separste areas with appcopslate medical eqssipment, and supplies. 3. Guidelines for prepasation of chemothesapr, TPN, and other stesle compounded medications are used in the medication pscpasation process D4. Suifprepasing/compotinding stesile products medications ace trained and competent ia the principles ‘of medication preparation and aseptic tecliniques and are provided resousces to suppost the medication prepazation process 5. Guidelines for use of single-use and multidose vials ace identified and implemented in the mediestion puosess, 1 6. Medications stored, prepared, and dispensed from areas outside the pharmacy (for example, patient case ssaude) comply with the safety and cleanliness measuses sequised in the phammacy, CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees Standard MMU.5.1 Medication prescsiptions or orders ase reviewed for appropsiatencss. ®) Intent of MMU.5.1 Good medication management includes two reviews of each preseziption or onder: + The appropsiaceness of the medication for the patient and his or hes clinical needs performed at the time the medlicatio is peesecined ox osdesed + The veufication at the time of administration that the medication dflexactly as osdcved oz peesczibed (we MMU.1, ME 1) ‘The dust seview is conducted by someoue other than the ordesing iividual, such ae a licensed pliarmacist, or other licensed professional, such as a nusse or physician, competentin the katowledge required for a fall appeopsisteness ceview. Each prescription or cndes, newly psetesibed o: orclesed ic reviewed for appenpsiatences, jaicloding a) through g) below. A new appropriateness review should be couducted hea the dosage or other approptiateness factors noted below change; for example, wehen new drugs ace presetibed and therapeutic duplicatioa may be aa issue. The hospital defines what patient-specific information is eeghized for the approptiatencss review of the order or prescription. The appeapslateness ceview ie conducted by those individuals eoliapeteatt0 do sa by visme of education and tusining, as specified by puivileging for licensed lidepeadent practitioners or demonstrated competency for nuuses or other professionals, in the seview process. This individual may be thepbarmacist dusing the normal operation hhouss of the phasmacy. The process to candice ai appsopiateness ceviewr (the fest ceview) far an osdes or prescription prior to dispensing includes evaluation by a tualuedprofessiowal of 8) the appropriateness oF HE Mimus, dose, feqency, and fouRBof administiation; b) therapeutic duplication: ©) zeal or potential allegies or sensitivities; 4) seal or potential integactions between the medication and other medications o: foods ©) vatlation from hospital entevia fax tse: f) patiomt’s Weighs and orl PfSiologieal kfo:macions nd 2) other conteaindiestions Appropilateness reviews must Be conductedheven when cletmstauces are not ideal. For example, ifthe ceatial pharmacy ox @lunit pharmacy is nobopen, andthe drug will be dispensed fkom stock on the aucsing wait, the ppeopsisteness geview anay he condhered in conjuction with the verification ceview whea the oxrlesing indivisisal vill aduiiister the iedication and monitor the patient When the ovdecing indiidal is not available to adimiaistec the mediestioa and monitos the patient, cxtieal clements of the approptistehess review may be performed by other trained individuals for administuation of the first dose of the medicstiou. The eiitire appropriateness seview must be performed by a licensed pliarmacist, or ther licensed professional, sneh as a asse or physician, competent in the knowledge sequiced far a fall approptisteness review within 24 hous. Ceitieal elements of an appropriateness review include at least the following bb) Allergies 2) Lethal doug/deug intesnetions ) Weight-based dosing Potential organ toxicity for example, administation of potassium spasing divseties in paticats with senal shiluse) ‘The exitical elements of the approptiateness review may be condveted by other licensed trained individuals ducing times when the pharmacy is not available, These individuals have documented taining in condhcting the eciical CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internation CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees clements of the approptistencss zeview aud will be supported by reference matesials, computer programs, and other sesousces. Thus, when a physician ealls in a new medication ordex dusing the night for a patient che trained. individual will wsite down and sead back the order and thea conduct an appropriateness review for the identified cutical elements. A second review will be zequited by a licensed phanmacist or other licensed professional, such as a mnuse of physician competent in the knowledge sequited fox a full appropsateness ceview, within 24 hous “There may be cizcumstances ia which the full appuoptisteuess zeview ie uot pasctical, such as in aa emergency of ‘when the ordering physician s present fox oxdening, administering, and monitoring of the patient (for example, the opesating theatce or the emergency depactment), or with oral sectal, or injectable counteas i i radiology ot diagnostic imaging whese the medication is part of the procedute. -creational To facilitate seview, there is a record (profile) for all medication administef€dlto a patient except emergency medications and those administered as past of a procedue. This record may be kept in the phsumacy and/or be online for review when the pharmacy is closed. This information is éssentil ro the appropsiateness review. When computes progsame ace used to esoss-check dase dang istesnetions andcmis alesies, the paogeams ase current and updated according to zecommendations of the progsam manufactug’s. In addition, when print reference matesials are used, the most eurkent versions of the matesials are utilized, Measurable Elements of MMU.5.1 1 1. The hospital defines the patient-specific informatio ceqquiced fSban effective sevil process, and the source or availability of this iafosmatiom is available at ll ties when the phiasmacy'is epen or closed. a _Apact fiom exceptions identified la the latent, ach prescription oc ores is ceviewed foe appcopeiateness by ‘licensed professional competent in the knowledze sequized to perform a fll appropuisteness zeview prior to dispensing and administration and includes elements a) through) in the intent. 3. Individuals permitted go conduct appropriaceness seviews are judged Competent 10 do so and axe [peovided sesonaes to suppost the ceview process, 4. When the designated licensed professional is not available co perto#m the foll appropriateness review, a ‘esined iadividital ennduets ancl dacs a sevlew of csitieal elements in) theough in the intent foe the fist dose and a fill appropuiateness review is conducted by the designated licensed professional swithisl 24 Wouss, D5. Review is faciltate@iy 2 record (profile) for all Patients receiving medications, and this record is available atall times when the pharmacy is open or closed. 6. Computer programs and plint ceferenée materials, when used to ceass-check daugs for deug/deug intessetins and allergies, are cuzent and tpdated. Standard MMU.5.2 A system is used to safely dispense medications in the tight dose to the right patient at the sigh time, Intent of MMU.5.2 Medication use has become increasingly complex, and medication errors ase a major eause of preventable patient Inari, A naificm system foe dispeating and distibuting mediestione ean help ceduce the sake of medication exsnes ‘The hospital dispenses medications in the most ready-to-administer fom possible to minimize opportunities for error during distribution and administration, The issue of the most ready-to-administer form becomes enucial chasing emergent simtations in which immediate administration of the medication is life-saving. For example: sing resuscitation. The ceatzal phamnacy aud otlier medication-distubution points throughout the lospital vse CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE{©2019 Joint Commission Internationa CU Stade fox Hoopsale Drsit "ch Ed Revsiont ‘MALU Chapees the same system, The system supports accurate dispensing of medications in a timely manues, ‘When medications ate prepared by someone different from the person administering the medication, the 1isk of a medication error is increased. Thus, when 2 medication is removed from its original packaging or prepared and dispensed in a diffezent form /container—and not immediately administezed—the medication must be labeled with the name of the medication, the dosage /eancentestion of the medication, the date of puepasation, the date of cexplzation, and two patient ideutifiers, When medications are prepased for use dusing a stugical procedure in the ‘opezating theatre and waused postions ate discarded immediately following the susgieal proceduse, the patient's same and expisation date may aot he aecessasy Measurable Elements of MMU.5.2 D1. Medications ate dispensed in the most seady-to-administer fous available 2 The system supports accurate and timely dispensing and ddeumentation of dispensing practices a ‘After prepatation, medications aot immediately admistttered are labeled with the asme of the niedication, the dosage/ concentration, the date prepited, the expiration date, and two patient identifiers Administration Standard MMU.6 (Quulidied individuals penmitted to administer medigations ase identified and document the medications that ase administered in the patient siiedicaltecos. Intent of MMU.6 Administering a medication to test a patient cequices specific Knowledge aad expevience. Each hospital is responsible for identiffing those iidivicwals with the coquisite knowledge aud expetieace and who ase also perinitted bp lidensteyeestification, las, oF regulations to administer medications. A hospital may place limits on medicasiod administration Bpan individual, such as for Controlled substances or sadioactive and investigational medications, In emergency situitions, che hospital identifies ny additional individuals permitted 0 administer medications) The medical secoagbef each patient ‘ho seccives medication contains a list of the medications puesexibed or ocdesed for the patlenand the dotage and times the medication was administered, Tacluded aze medications aduniisteued “at needed?Uf this infomation is uecouded on a sepaate medication foun, the fomnis inserted in she patict’s medical secord at dischatge-ox transfer, Measurable Elements of MMU.6 QL. The hospital idesrifies chore indivietals, by job description o: ‘administer medications palvileging peacess, authosized to 2 Thereis a process to place limits, when appropsiate, on the medication administsation of individuals, G 5. Medication aduinistration is secossed for cash dose, CONFIDENTIAL DO NOT COPY — DO NOT DISTRIBUTE