Effective August 1, 2016, TJC added three additional policies to the list of documents required for hospitals on the first day of survey. These have been added to the Hospital Accreditation Program Document List in the updated Survey Activity Guide and are as follows:

• Medication management policy (which defines what is a complete medication order and therapeutic duplication)
• Abuse and neglect policy for inpatient and, if applicable, for ambulatory sites
• Fall risk assessment and policy

The addition of these policies to the Documents List may seem to be a minor change. However, it would be wise to anticipate that added attention will be given by surveyors not only to the written policies but also to their consistent implementation hospitalwide. So, this month, we are taking a look at the requirements for the hospital’s medication ordering policy. In future issues, we will address the other two new policies required.

Medication management policy: The relevant standard here is MM.04.01.01 “Medication orders are clear and accurate.” Element of performance # 2 states “The hospital has a written policy that defines the required elements of a complete medication order.” Interestingly, this standard does not refer to therapeutic duplication as a topic that needs to be addressed in the medication ordering policy. However, standard MM.05.01.01 EP 8 directly addresses the issue of therapeutic duplication. It requires that a pharmacist review the appropriateness of all medication orders for allergies, interactions, appropriateness, relevant lab values, and therapeutic duplication. Note: therapeutic duplication is defined as “the practice of prescribing multiple medications for the same indication without a clear distinction of when one agent should be administered over another.”

In order to see if the issue of therapeutic duplication has been coming up recently on hospital surveys, we checked our database of survey findings and found that, indeed, this issue has arisen on several recent surveys. Examples of findings include:

“At the time of admission, a patient had orders for acetaminophen 650 mg PO q 4 hours PRN, mild pain or fever. There was also simultaneously an order for ibuprofen 400 mg PO q 4 hours PRN mild to moderate pain. This constitutes therapeutic duplication.”

“Orders for 2 medications (Klonapin and Thorazine) were seen to have the same indications of irritability and anxiety.”

Clearly, the issue of therapeutic duplication is being pursued by surveyors as they conduct tracers and review medical records. So, in order to be prepared for this area of focus, we recommend the following actions as part of your ongoing readiness program:

• First and foremost, engage your medical staff leadership in the initiative to address therapeutic duplications.
• Research best practices and policies on this topic.
• Review your current medication ordering policy to ensure it meets all the requirements of MM.04.01.01 EP 2 – 5 and also reflects best practice.
• If the policy does not currently address the issue of therapeutic duplication, expand it to include this issue.
• Educate prescribers and nurses about therapeutic duplication as a patient safety issue that can lead to excessive or unintended use of medications, medication errors, and adverse drug reactions.
• Be clear about what actions should be taken by pharmacists and nurses when they receive an order that contains a therapeutic duplication. Since this may likely involve clarifying the order with the prescriber, make sure that the medical staff supports this process and will be responsive to requests for clarifications.
• Have your Pharmacy & Therapeutics Committee review and analyze data regarding the frequency of therapeutic duplication orders so that patterns and trends can be identified and addressed.
• Consider including therapeutic duplication orders as an indicator in the ongoing professional practice evaluation (OPPE) for your medical staff so that individual practitioner performance can be tracked.

For more on this topic, check out the presentation Therapeutic Duplication Overview by B.E. Consulting which is available to the public on the internet. Although likely developed for an acute care medical setting, the content is readily applicable to psychiatric hospitals and may be a useful resource as you tackle this initiative.