Joint Commission Clarifies High Alert and Hazardous Medications

PUBLISHED: Feb 11, 2019
Relevant to: All Healthcare Organizations

The Joint Commission (TJC) recently responded to a Frequently Asked Question (FAQ) about management of high alert and hazardous medications. According to TJC, posting an internet-generated list of these types of medications does not meet the requirements of standard MM.01.01.03.

The intent of MM.01.01.03 is to have the organization develop an organization-specific list of high-risk/high alert medications from a review of external data extracted from authoritative sources, the organization’s unique utilization patterns of drugs, and internal data collected in regard to medication errors and sentinel events.

According to TJC, when developing a high alert and hazardous medications list, the following should be evaluated:

  • Medication utilization patterns that may be unique to the organization
  • Internal data about medication errors, sentinel events, known safety issues, etc.
  • Information available from sources, such as:
  • The medication manufacturer
  • State pharmacy boards
  • Regulatory agencies, such as the CDC, FDA, OSHA, USP, etc.
  • Institute for Safe Medication Practices, (ISMP) and other professional resources
  • Applicable law and regulation
  • Services provided and patient population served

Each organization must also determine where/how the list of medications is documented and made available to practitioners/staff involved in medication ordering, management and administration practices. According to TJC, examples of this might include, but are not limited to:

  • Indicating on a pre-populated list obtained from an external source which medications are available for administration
  • Developing separate lists for medications identified as high-alert and/or hazardous

Organizations must also determine how staff and practitioners are educated regarding processes for managing these categories of medications.

Included with today’s notice is an example policy related to the management of high alert and hazardous medications. Also included is a link to the TJC FAQ.

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