SUPPLEMENTAL HANDOUT FOR INPATIENT PHARMACISTS

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1 The main navigation buttons at the bottom of each screen allows you to Pause/Play, Advance, and Go Back. The Pause/Play button will flash to let you know you can advance to the next screen. There is no audio for this course. You will only be able to view current and previous slides. Other navigational instructions are in blue. Definitions of commonly used terms and acronyms can be accessed at any time during the course under the Glossary tab at the top right of the screen. Frequently Asked Questions (FAQs) can be accessed at any time during the course under the FAQ tab at the top right of the screen. Supplemental handouts can be found under the Attachments tab at the top right of the screen. Inpatient Nursing Unit Inspections Outpatient ATC/Clinic Inspections Clinic and Nursing Unit FAQ You must pass the quiz with an 80% to complete the course. 1

2 Overview: This course will: 1) Briefly discuss the Joint Commission (JC) Standards, Institutional Policies, and other patient safety guidelines/regulations that are monitored via monthly clinic and nursing unit inspections. 2) Review the issues often seen on ZIP (Zone Inspection Program) rounds. 3) Introduce modifications in the inspection process and the electronic form used for documentation and tracking. Audience: All operational pharmacists (Inpatient, ATC, Clinic). Duration: This course will take approximately 30 minutes to complete. After completing this course, you will be able to: Identify the JC Standards, Institutional Policies, and other patient safety guidelines/regulations associated with the monthly clinic and nursing inspections. Discuss the common non-compliant issues found in the clinics and nursing units. Identify steps for access to the electronic inspection forms on the intranet for documentation and tracking. 2

3 To ensure consistent patient safety practices in all patient care areas. To ensure all patient areas are compliant with Joint Commission Standards, Institutional Policies, and other guidelines/regulations. The medication management standards most frequently scored as non-compliant are monitored monthly in the nursing/clinic unit inspections by the pharmacy MM Medication Storage MM High-Alert Medications MM Medication Labeling 3

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11 What is secure? CLN0539 Medication Security Policy Locked cabinets or locations that prevent all unauthorized access to the medication. Locations under constant surveillance to prevent all unauthorized access to the medication. Who is considered to be unauthorized personnel? Unauthorized staff Patients Visitors Refer to CLN0539 Medication Security Policy for definition of authorized personnel. 11

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27 I Care About Our Patients Actions Review CLN1042 High Alert Medication Policy. Verify that insulin is not mixed with other drugs. Verify that insulin is stored in labeled bins with High Alert Warnings. Check hazardous medications for appropriate auxiliary labeling to identify them as hazardous. Chemotherapy Investigational 27

28 All controlled substances are secured and are within their labeled expiration date. Inpatient Controlled Substances for discharged patients are returned to the pharmacy. Controlled Substances not stored in Controlled Access Cabinets (Pyxis ) are counted every shift. Actions Review CLN0551 Medication Brought into the Hospital by the Patient Policy. Verify that medications brought from home are authorized for use at MD Anderson. Check that medications brought from home are identified prior to use, labeled, and secured. 28

29 Verify that all medications (IV s and non- IV s) for discharged patients are returned to the Pharmacy. Audit 3 controlled substances on 2 patients for 24 hours each. Audit must include one PCA/Epidural order if present. If PCA/Epidural not present, an audit on 2 patients must still be completed. Record MRN and drugs audited Verify an MD order for each drug Verify each drug removed from Pyxis is documented on MAR 29

30 Pyxis Instructions for Audit Select patient on the Pyxis workstation. Print a Charges and Credits report. The time span of the report should be enough to gather data for 3 controlled substances for 24 hours. Compare the Pyxis report to the patient s MAR. Note any discrepancies, such as a dose not charted. If the MAR is not available in the chart, it can be found under Scanned Documents in Clinic Station. URL: Click on URL above to go to secured site. If opening for the first time, add URL to Favorites Name: Nursing Unit Inspections LOGIN: Novell username and password 30

31 Forms may be printed and used during inspection to record findings. Enter comments for non-compliant issues. Do not use patient or staff names or identifiers in the comments. Inspections are not complete until entered online. Unit Inspection Audits and Controlled Substance Audits are separated into 2 forms. Both audits must be completed for compliance. Inspections must be completed by the end of every month Will be tracked via reports Inspections go directly to nurse managers of each unit. 31