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7/19/2002

JCAHO Retreats on Retrospective Pharmacy Review for CPOE Systems

Kate Traynor

In an unusual move, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has withdrawn its proposal to allow hospitals with a computerized prescriber order-entry (CPOE) system to forgo prospective pharmacy review of medication orders.

The proposed change to one of the medication-use standards for hospitals read: "When a CPOE system is in use, a retrospective review of medication orders by a pharmacist is required, as soon as possible, after administration of the drug."

"We have taken that section out of the standards," said Darryl S. Rich, director of surveyor development and management for JCAHO. Rich made the comment in June, after he spoke at an educational session on upcoming JCAHO standard changes during the ASHP Summer Meeting in Baltimore.

Rich said JCAHO had received "a lot of comments from pharmacists and physicians" expressing opposition to the retrospective review provision. Some of the health professionals who sent JCAHO formal comments about the standard also sent copies of their correspondence to ASHP, which had urged hospital and health-system pharmacy directors and top officials of affiliated state chapters to comment on the proposed revision.

The Surveyor Says ...

At an educational session held at ASHP Summer Meeting 2002 in Baltimore, officials from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) discussed medication-use issues that arise during accreditation surveys.

Unit dose packaging: "We do say in the new [medication-use] standards that you have to use the unit dose when it is commercially available from the manufacturer," said Darryl S. Rich, JCAHO director of surveyor development and management. "There are some products that are available in unit dose [form] that organizations are choosing not to buy because it's cheaper to buy in bulk," he said. "We find that a lot in psych[iatric] hospitals; and that is not going to be considered an acceptable practice."

Repackaging: Kenneth G. Hermann, a hospital consultant for Joint Commission Resources Inc., said pharmacists need to directly supervise the process of converting bulk drugs into unit dose packaging. "Many times, this is relegated to the technicians," he said. "Frequently, we will not see a pharmacist getting involved at all in checking what's going into those unit doses."

Product preparation: In visits to ambulatory care clinics, Hermann said, "I see allergens being diluted by people who don't really understand what they're doing." Hermann described such situations as "the unqualified leading the uninitiated through the unknown." He said the pharmacy needs to be involved in overseeing the preparation of products throughout the facility.

Rich raised the issue of product preparation in home care settings. "People are still sending nurses into the home to prepare Rocephin [Hoffman-La Roche Inc.'s ceftriaxone product] i.v.'s ... as opposed to the pharmacist doing it back in the pharmacy," he said. "Clearly, that would not be acceptable to us."

Expired drugs: "We do find that there's an awful lot of outdated medication still stored in areas of hospitals," Hermann said, citing ophthalmology treatment rooms as the most problematic.

Legibility of medication orders: "In some of the places where I go, it's very difficult to read orders," Hermann said. At one large teaching hospital he worked with recently, personnel needed a physician's help in reading 40% of the orders. "That's criminal, Hermann said.

Drug shortages: "You have to address drug shortages as part of your emergency-preparedness plan," Rich said. "If there was an outbreak, for instance, of anthrax, you could have a run on a particular antibiotic, and you have to plan for how you would deal with this situation." 

"I have led or participated in a number of studies that have established the benefit of CPOE," wrote physician David W. Bates of Brigham and Women's Hospital in Boston. "However, we have continued to have pharmacist review of prescriptions before drugs are dispensed or administered, and our experience strongly suggests that this continues to be an extremely important safety check." 

Bates told JCAHO that physicians, when using a CPOE system, "commonly override even the strongest warnings" generated by the program. "We have had many instances in which physicians wrote prescriptions for patients with severe allergies—even anaphylaxis—to a medication, and yet the order was not changed at the first warning, but when the pharmacist calls."

Steve Kleinglass, director and chief operating officer of the Department of Veterans Affairs (VA) Medical Center in Minneapolis, similarly stressed to JCAHO that CPOE systems do not prevent prescribing errors. Kleinglass, who noted VA hospitals’ early adoption of CPOE systems, wrote that, despite the use of this technology, "one third of our 'near miss' medication incidents are prescribing errors prevented by pharmacy review."

Kleinglass cited specific examples of prescribing errors that his pharmacy staff has averted by prospectively reviewing medication orders generated through the hospital's CPOE system, including:

  • Enoxaparin 900 mg was ordered instead of a dose in the customary range of 30–150 mg, 
  • Propranolol was ordered instead of propofol, and 
  • Esmolol and atenolol (a therapeutic duplication) were ordered for the same patient.

Thomas D. Keith, pharmacy director for the Mayo Clinic and St. Luke's Hospital in Jacksonville, Florida, where a pilot test of a CPOE system is under way, told JCAHO that "prospective review by a pharmacist is paramount in the selection of the appropriate drug." Keith said his pharmacy staff has spent more time on medication-safety issues during the pilot program than before the CPOE system was implemented.

With the elimination of the controversial provision in the medication-use standard, JCAHO envisions only two situations in which the hospital pharmacy need not review a medication order before the drug is dispensed.

"[One] exception is stat or emergency orders," Rich told those who attended the educational session in Baltimore. "The way we define that is…clinical harm would have to come to the patient if there were a delay in the medication [administration] caused by review."

Kenneth G. Hermann, a hospital consultant for Joint Commission Resources Inc., a JCAHO subsidiary, described to session attendees the other exception:

"You don't need to review the orders when a physician is directly involved in the supervision of the care," he said. "In the emergency department or in surgery," he explained, "we would not expect the pharmacist to be reviewing that [medication] order."

The new medication-use standards will be incorporated into JCAHO's Comprehensive Accreditation Manual for Hospitals. Although JCAHO initially intended to have the new medication-use standards take effect next year, Rich said in early June that the planned effective date is now January 1, 2004.