Automated dispensing cabinets settings and medication dispensing processes should be evaluated in accordance with federal and state regulations. These may include requirements established by entities such as the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), DNV, State Board of Pharmacy (BOP), Department of Public Health, or other applicable regulatory bodies. Specific requirements may vary.
There currently is not specific language regarding auto-verification in the Medication Management Standards for Hospital Accreditation.
A summary of select Medication Management Standards for Hospital Accreditation that pertain to pharmacist order review and medication dispensing are listed below.
Medication Management (MM)
Label MM.05.01.01
Standard A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital
Element of Performance
1. Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation (including sudden changes in a patient’s clinical status), in accordance with law and regulation.
Note 1: The Joint Commission permits emergency departments to broadly apply two exceptions in regard to Standard MM.05.01.01, EP 1. These exceptions are intended to minimize treatment delays and patient backup. The first exception allows medications ordered by a licensed independent practitioner to be administered by staff who are permitted to do so by virtue of education, training, and organization policy (such as a registered nurse) and in accordance with law and regulation. A licensed independent practitioner is not required to remain at the bedside when the medication is administered. However, a licensed independent practitioner must be available to provide immediate intervention should a patient experience an adverse drug event. The second exception allows medications to be administered in urgent situations when a delay in doing so would harm the patient.
Note 2: A hospital’s radiology service (including hospital-associated ambulatory radiology) will be expected to define, through protocol or policy, the role of the licensed independent practitioner in the direct supervision of a patient during and after IV contrast media is administered including the licensed independent practitioner’s timely intervention in the event of a patient emergency.
2. When an on-site pharmacy is not open 24 hours a day, 7 days a week, the following occurs:
- A healthcare professional determined to be qualified by the hospital reviews the medication order in the pharmacist’s absence
- A pharmacist conducts a retrospective review of all medication orders during this period as soon as a pharmacist is available or the pharmacy opens
4. All medication orders are reviewed for the following:
- Patient allergies or potential sensitivities
- Existing or potential interactions between the medication ordered and food and medications the patient is currently taking
- The appropriateness of the medication, dose, frequency, and route of administration
- Current or potential impact as indicated by laboratory values
- Therapeutic duplication
- Other contraindications
11. After the medication order has been reviewed, all concerns, issues, or questions are clarified with the individual prescriber before dispensing
Standard Label | MM.05.01.11
Standard The hospital safely dispenses medications
1. The hospital dispenses quantities of medications that are consistent with patient needs.
Note: This element of performance is also applicable to sample medications.
2. The hospital dispenses medications and maintains records in accordance with law and regulation, licensure, and professional standards of practice.
Note 1: Dispensing practices and recordkeeping include antidiversion strategies.
Note 2: This element of performance is also applicable to sample medications
3. The hospital dispenses medications within time frames it defines to meet patient needs.
4. Medications are dispensed in the most ready-to-administer forms commercially available and, if feasible, in unit doses that have been repackaged by the pharmacy or licensed repackager.
Standard Label | MM.05.01.13
Standard The hospital safely obtains medications when the pharmacy is closed
1. The hospital follows a process for providing medications to meet patient needs when the pharmacy is closed.
2. When non-pharmacist health care professionals are allowed by law or regulation to obtain medications after the pharmacy is closed, the following occurs:
- Medications available are limited to those approved by the hospital
- The hospital stores and secures the medications approved for use outside of the pharmacy
- Only trained, designated prescribers and nurses are permitted access to approved medications
- Quality control procedures (such as an independent second check by another individual or a secondary verification built into the system such as bar coding) are in place to prevent medication retrieval errors
- The hospital arranges for a qualified pharmacist to be available either on-call or at another location (for example, at another organization that has 24-hour pharmacy service) to answer questions or provide medications beyond those accessible to non-pharmacy staff
