CSR News and Information
Next 2010 CSR workshops: September 22 & 23
Topics Updated - 4/10
- Website Transitioning to JCR National CSR Website
- Welcome New CSR Consultants
- Approved Abbreviations
- Medication Product Storage: Betadine
- Expiration of Opened Medications
- Spiked IV Bags in the Procedural Areas
- Corrected During Survey
- Procedural Verbal Order Update
WEBSITE TRANSITIONING TO JCR NATIONAL CSR WEBSITE
Over the next few weeks the content on the Resources page will be moving to the Joint Commission Resources national CSR website. To log onto the national CSR webpage go to www.jcrinc.com, select product and services and then click on CSR. Please click on the following information. . NATIONAL CSR.
WELCOME NEW CSR CONSULTANTS
Two new CSR Consultants have joined the Southwest Region. Diane Friedman RN, MA, MS who resides in Albuquerque, New Mexico has been a Joint Commission Resources Consultant for a number of years. To learn more about Diane click on the following link. Friedman Bio. Elizabeth Maish RN, MSN, CPHQ from Tucson, Arizona joins the CSR team following her tenure as the Director of Quality at Tucson Medical Center. Over the next few months Elizabeth will be assigned to hospitals in Arizona and Texas.
APPROVED ABBREVIATIONS
Q: When the National Patient Safety Goal regarding abbreviations moved to Information Management chapter, language changed. The requirement now reads “a policy for approved terms and definitions, abbreviations, acronyms, symbols and dose designation approved for use and prohibited from use.” This appears to be a change in requirements. Can you advise and clarify the changes?
A: (from Pat Adamski): I have shared your concern regarding the language with the Division of Standards and Survey Methods. There is no change in the requirement. A list of approved abbreviations is not required.
MEDICATION PRODUCT STORAGE: BETADINE
Q: As you know, Betadine® and other wound care products are classified (with a National Drug Code, or NDC, number) as medication.If these items are kept in a clean utility room that is unlocked and determined to be okay per a risk assessment, does this meet the intent of the standard?
A: (from Sophie Duco): The organization would need to ensure these medications are only accessible to authorized persons. The organization would need to determine who is authorized to have access to medications, in compliance with law and regulation. Those authorized to have access to medications would need to be educated to their role in the medication management system. Job descriptions would also reflect that role and responsibilities associated to medication management.
The organization may wish to consider conducting a risk assessment. The risk assessment would include, but not be limited to, the factors mentioned above. Additional consideration should be given to who has access to the room, is the room in an area frequented by authorized staff, the history of diversion or tampering within the organization, populations served, geographic location, and so on. The organization would define “secure” based on that risk assessment and would act accordingly. At time of survey, surveyors may ask to see evidence of a thorough risk assessment as well as evidence of compliance with law and regulation regarding who is authorized to have access to medications.
EXPIRATION OF OPEN MEDICATIONS
Q: Some of my organizations that have recently been through survey are being told by surveyors that the expiration date of the item should be on that item versus the open date. For example if insulin is good for 28 days, the expiration date (28 days later) should be on the bottle versus the open date. Is this required or recommended?
A: (from Pat Adamski): We are still discussing this. The standards support the expiration date. The expiration date also makes sense—if you use the date opened, every nurse then has to figure out what the expiration date is.
SPIKED IV BAGS IN PROCEDURAL AREAS
Q: If IV bags are spiked, in a same day surgery area, the morning of surgery with the staff's understanding that they discard all IV bags at the end of the day, does each bag need to be dated and timed?
A: (from Cynthia Leslie) Yes, all IV bags that are spiked in same day surgery and not used immediately would need to be labeled. One risk that may occur if the bags are not labeled is that they may not be discarded at the end of the day and used the next day after they have expired. Please review IC.02.02.01, EP3 which addresses disposing of medical equipment, devices and supplies. Also, if the patients were to remain in the hospital overnight or longer, staff would need to know how long the IV bag would be hanging.
CORRECTED DURING SURVEY
When George Mills, Senior Engineer, at The Joint Commission spoke at the CSR workshop this month, he shared news that some minor items that were noted during the survey as out of compliance would not be scored if corrected during the survey. This is a departure from The Joint Commission's policy that any non-compliance found during surveys would be scored, even if corrected during the survey. Please see George's presentation on the Resources page for more details.
PROCEDURAL VERBAL ORDER UPDATE
heck areas such as cardiac catheterization, interventional radiology, endoscopy and look at the organization's sedation record. Many are not set up to take an order as a verbal order and have the MD sign off on each order. Note the following question posted to the Standards Interpretation Group.
Q: During a procedure a nurse takes a verbal order, writes it down, reads it back and then the physician verifies that order. Because sedation is given in increments, is it acceptable to have the physician sign the appropriately written verbal order as a group of orders versus signing each individual order for each increment of the sedation medication?
A: Based upon the information submitted, it sounds as if the physician is giving more than one order. Each order would be implemented as given. Each order would be separate, dated and timed and each order needs to be individually signed by the physician. Cynthia Leslie, Standards Interpretation Group.