Pharmacy Medication

Citation

TJC EM.12.02.09

The hospital has a plan for managing resources and assets during an emergency or disaster inc...

The hospital must maintain a plan for tracking, monitoring, and replenishing essential resources and assets during and after an emergency incident.

Citation

TJC LD.13.01.09

The hospital has policies and procedures that guide and support patient care, treatment, and...

The hospital must develop and implement policies to guide patient care, including medication safety and surgical standards.

Citation

TJC MM.11.01.01

The hospital safely manages pharmaceutical services.

The hospital must procure, store, control, and distribute drugs and biologicals in accordance with laws and standards.

Citation

TJC MM.11.01.03

The pharmacy is a resource for medication-related information.

The pharmacy must provide professional staff with access to information regarding drug therapy, interactions, and administration.

Citation

TJC MM.12.01.01

The hospital selects and procures medications.

The hospital must maintain a formulary that includes medication strength and dosage, accessible to those managing medications.

Citation

TJC MM.13.01.01

The hospital safely stores medications.

The hospital must safely store medications, including controlled substances and radiopharmaceuticals, to prevent diversion.

Citation

TJC MM.14.01.01

Medication orders are clear and accurate.

The hospital must ensure medication orders are clear, accurate, and documented by authorized practitioners.

Citation

TJC MM.15.01.01

The hospital safely prepares medications.

The standard addresses pharmacist supervision, sterile compounding policies, staff competency, compounding environments, storage, labeling, quality assurance, and radiopharmaceutical preparation oversight.

Citation

TJC MM.16.01.01

The hospital safely administers medications.

The standard addresses medication administration under law, practitioner orders, standards of practice, medical staff policies, and patient or caregiver self-administration procedures.

Citation

TJC MM.17.01.01

The hospital responds to actual or potential adverse drug events, significant adverse drug re...

The standard addresses hospital policies and processes for reporting and evaluating adverse drug events, adverse drug reactions, medication incompatibilities, and medication administration errors.

Citation

TJC MM.18.01.01

The hospital establishes antibiotic stewardship as an organizational priority through support...

The standard addresses leadership, coordination, documentation, training, guideline adherence, and tracking for a hospitalwide antibiotic stewardship program.

Citation

TJC MS.16.03.01

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Citation

TJC NPG.06.01.01

Pain assessment and pain management, including safe opioid prescribing, are identified as an...

The hospital establishes leadership, staff education, and resources for pain management and safe opioid prescribing practices.

Citation

TJC NPG.06.02.01

The hospital assesses and manages the patient’s pain and minimizes the risks associated with...

The hospital implements processes for screening, assessing, treating, and reassessing patient pain while managing risks associated with opioid treatment.

Citation

TJC NPG.11.03.01

The hospital manages utility systems.

The hospital manages utility systems, including written procedures for utility disruptions and emergency backup policies for essential medication dispensing equipment and medication refrigeration.

Citation

TJC NPG.12.01.01

The hospital’s leadership team ensures that there is qualified ancillary staff required to me...

Hospital leadership ensures adequate qualified ancillary staff across service lines, including medical records, dietetic, pharmacy, infection prevention, and surgical services, with specified qualifications and supervision.

Citation

TJC NPG.14.01.01

The hospital safely manages pharmaceutical services.

The hospital ensures safe pharmaceutical services by requiring qualified review of medication orders when the pharmacy is closed and by governing automatic dispensing cabinet overrides.

Citation

TJC NPG.14.02.01

The hospital selects and procures medications.

Requires the hospital to select and procure medications, standardize drug concentrations, and communicate medication shortages and substitution protocols to staff.

Citation

TJC NPG.14.03.01

The hospital labels all medications, medication containers, and other solutions on and off th...

Requires labeling of all medications, containers, and solutions on and off the sterile field in perioperative and other procedural settings, including required label content and two-person verification.

Citation

TJC NPG.14.04.01

The hospital reduces the likelihood of patient harm associated with the use of anticoagulant...

Requires the hospital to reduce patient harm from anticoagulant therapy through approved reversal and perioperative protocols and use of unit-dose, prefilled, or premixed products when available.

Citation

TJC NPG.14.05.01

The hospital maintains and communicates accurate patient medication information.

Requires the hospital to obtain, document, reconcile, and communicate accurate patient medication information across care transitions.

Citation

TJC NPG.14.06.01

The hospital has an active antibiotic stewardship program.

Requires the hospital to maintain an active, multidisciplinary antibiotic stewardship program that monitors antibiotic use.

Citation

TJC PE.02.01.01

The hospital manages risks related to hazardous materials and waste.

Requires the hospital to inventory, label, handle, store, and dispose of hazardous materials and waste, including radioactive, chemical, gas, vapor, and regulated medical waste, while protecting patients and staff.

Citation

TJC PE.04.01.01

The hospital addresses building safety and facility management.

Requires the hospital to comply with the Health Care Facilities Code and maintain essential equipment, ventilation, lighting, temperature control, and supplies in pharmaceutical, patient care, food preparation, and nuclear medicine areas.

Citation

TJC PI.12.01.01

The hospital collects data.

Requires the hospital to collect, analyze, and act on data regarding medical errors, adverse patient events, and quality improvement projects.