Be aware! The Joint Commission standard on medication administration (MM.06.01.01 EP 3) is one surveyors frequently cite for both Hospitals and Behavioral Health Care organizations.

In fact, it’s typically because medications are not administered consistent with orders. But, there are situations where variation from medication administration can be acceptable based on patient preferences. So, let’s take a look at the details on this topic.

Joint Commission Standard: Medication Administration – Hospitals (MM.06.01.01 EP 3)

First, the medication administration standard for hospitals states the following:

“Before administration, the individual administering the medication does the following:
– Verifies that the medication selected matches the medication order and product label
– Visually inspects the medication for particulates, discoloration, or other loss of integrity
– Verifies that the medication has not expired
– Verifies that no contraindications exist
– Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route
– Discusses any unresolved concerns about the medication with the patient’s physician or other licensed practitioner, prescriber (if different from the physician or other licensed practitioner), and/or staff involved with the patient’s care, treatment, and services (See also MM.03.01.05, EP 2)”

Joint Commission Standard: Medication Administration – Behavioral Health Care and Human Services Organizations (MM.06.01.01 EP 3)

The requirement is very similar in the Behavioral Health Care and Human Services standards. Specifically, it states:

“For organizations that administer medications: Before administration, the staff member administering the medication does the following:
– Verifies that the medication selected matches the medication order and product label
– Visually inspects the medication for particulates, discoloration, or other loss of integrity
– Verifies the medication has not expired
– Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route
Note: For opioid treatment programs: Medications that are best administered by directly observed therapy (DOT)—such as tuberculosis and psychiatric medications—can be given at the same time as the opioid dose.
– Discusses any unresolved concerns about the medication with supervisory staff or the prescriber (See also MM.03.01.05, EP 2)”

Maintaining Standards Compliance While Incorporating Patient Preference

TJC acknowledges that “there are situations in which variations from medication orders based on patient preference may need to be considered.” They discuss this in their FAQ Medication Administration – Incorporating Patient Preference Into Medication Administration Practices. Specifically, this FAQ provides guidance on how to write orders to support medication administration based on patient preference; the use of policy or protocols; and medical record documentation.

Essentially, having the organizational policies in place to support the practice is the key to incorporating patient preference into medication administration. In addition, documenting why you administered the medication in a manner that varied from the order is critical.

Examples of scenarios where you can consider patient preference include situations such as:

• Multiple pain medications are prescribed based on the reported level of pain. A patient may desire to start with a less potent pain medication due to potential side effects of a stronger pain medication.
• Administering pain medication before a planned activity that may cause pain such as physical therapy or occupational therapy.

Additional Medication Management Resources

In addition to the TJC FAQ referenced above, there are excellent resources available from the Substance Abuse and Mental Health Administration for the safe administration of Medications for Substance Use Disorders | SAMHSA. Also, take a look at some clinical procedures for safe medication administration 6.2 Safe Medication Administration – Clinical Procedures for Safer Patient Care (opentextbc.ca).

In addition, check out the previous medication administration Barrins & Associates posts: TJC Medication Management Tracer: Survey Management Strategies; Medication Ordering and Therapeutic Duplication; Medication Instructions at Discharge.

Implications for your Joint Commission Survey

Joint Commission surveyors will evaluate medication management through both individual tracer and system tracer activities. During individual tracers, surveyors will review policies/procedures, inspect medication rooms/carts and pharmacies, review MARs, interview staff and patients, observe medication passes, and review medical records to ensure you’re following safe medication practices.

Surveyors will further explore gaps they’ve identified in safe practices through system tracers: Medication Management, Data Management, and Competence Assessment sessions. Be prepared for these sessions by making the following information available:

• Medication Management policies, procedures, and protocols including incorporating patient preference into medication administration practices
• Data regarding medication errors, near misses, ADRs, other
• Competence assessments related to safe medication practices for licensed clinical staff approved to prepare, dispense, and administer medications
• Pharmacy & Therapeutics Committee minutes for the last 12 months
• Policy regarding two patient identifiers required when administering medications.
• Medication Reconciliation policy
• Policy on authentication of verbal orders

Barrins & Associates Consultation

We’ve incorporated Safe Medication Management Practices into our 2023 Mock Survey and Continuous Readiness Consultations. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.