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Revisions to USP Chapter <797>

With the publication of the revised USP Chapter <797> which will go into effect November 1, 2023, the USP Chapter <800>, which directs processes to protect healthcare worker exposure from hazardous drugs, will also go into effect. The Joint Commission will incorporate compendially-applicable sections of the USP Chapter <800> within its survey process.

Design Processes for Complex Systems

Medication systems are extremely complex with multiple risk points. New medication therapies, new technologies, and new regulatory requirements add to the complexity. It’s critically important to design processes that, in addition to meeting Joint Commission and other regulatory requirements, provide optimal patient safety. The optimal performance of the pharmacy may also have financial consequences for the organization.

Improve your Medication Management Processes to Support Patient Safety and Effectiveness

Our team can provide your organization with suggestions on medication safety design, medication system optimization, and technology implementation to support patient safety and effectiveness. Collaborating with our team can help your organization to perform assessments and drive performance improvement in the following areas:

  • Joint Commission survey preparation
  • Assessing controlled substance security and diversion mitigation
  • Antibiotic stewardship
  • High risk medication processes including:
    • Sterile compounding and USP 797 compliance
    • Chemotherapy safety
    • Pediatric medication processes
  • Hazardous drug management and USP 800 readiness
  • Discuss policies, processes and order sets to align with Joint Commission requirements for Complex Medication Orders
  • Evaluation of medication-related technologies including computerized prescriber order entry, bar code medication administration, smart pump technology, and in-pharmacy technology
  • Specialty pharmacy and home infusion pharmacy under the home care accreditation

Working with JCR

We understand every organization has unique needs when it comes to medication management and safety- that is why we customize the team and tools for each engagement. Your engagement will begin with planning calls to clarify your needs, which will lead to defining the composition of the consultant team with the expertise to bring you direction and solutions. An agenda will be developed allowing for client input. Documents will be requested prior to the onsite engagement and will be housed in a SharePoint site that is limited to your organization and the consultant. An assessment will be performed where our consultants review documents, perform interviews and observations using tracer methodology and other means of assessment. A summary of findings will be developed and delivered during a closing conference followed by a robust report with the summary of findings and recommendations to help resolve the issues identified.

The JCR Advantage

Our team of skilled pharmacists have decades of hands-on experience in a variety of health care settings including acute care, ambulatory care, nursing homes, free standing pharmacies, and home health, including home infusion pharmacies and specialty pharmacies ― allowing them to work with organizations across the continuum of care. Because medication management and safety processes involve many disciplines, we can include other clinical experts such as infection preventionists, engineers, nurses and physicians on our customized engagements.

This unique multi-disciplinary team has the expertise in interpreting Joint Commission standards and the operational experiences to support your design of effective and sustainable medication processes. They are experienced in recognizing points of process breakdown, evaluating the root cause, and helping you create a targeted solution for improved performance using proven tools and methods.

Related Resource: Medication Management Made Easy

Provides the answers to the who, what, when, where, and why of Joint Commission standards for Medication Management (MM).

*The use of Joint Commission Resources consultative technical or advisory services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards.