News and Views for Healthcare Accreditation Professionals

Archive for December, 2011

Assessment of Bleeding Risk

It is apparent that there is an expectation that bleeding risk (baseline status) be established before any patient is placed on an anti-coagulant.  NPSG 03.05.01 EP 3 more or less states that a baseline status must determined.  We are fortunate if we are dealing with warfarin (INR) or Heparin (aPTT) but I have seen no really good examples of how to assess this status for other medications, and it is becoming more important because of new products on the market, such as Pradaxa (dabigatran etexilate) that have no laboratory value available to monitor the drug.  Lovenox (enoxaparin) can be monitored with an Anti factor Xa, but this test seems to be difficult to obtain.

I have just posted to the web site ( anticogulation information from Baptist Health System.  On Page 2, there is a section called “Bleeding Risk Factors” that I though would be a good starting point for such an assessment.

If any of the readers have a good way to assess baseline coagulation status, I would love to see it and post it.

Look in the NPSG section and get the file “Warfarin Dosing and Bleeding Risk Assessment.”


Critical Administration Times and Medication “Make Up” Policy

Recently posted to the web site in the “Medication Mangement” tab are two new policies.

CMS now allows hospitals to determine the criticality of medications and define what would constitute a “timing error”.   However, the organization must have a policy to support its decision or be held to the “+/- 30 minute” rule.  The policy post addresses this issue.

Also on the web site now is a “medication make up” policy.  This policy is an example of what to do if a critical medication actually is not administered at its scheduled time.

Also posted is a Duplications of Therapy policy for Pain.  Orders for multiple medications for the same indication (duplications of therapy) have resulted in a large number of RFIs and place MM.04.01.01 into the top 10 citations written.

These three policies are critical for a meaningful and safe medication administration system, and should be considered as part of the master medication administration policy.

CMS Approves use of Standing Orders

Well it seems to be official. Standing orders are now acceptable if:

1. The hospital policy specifically defines when they can be used, more or less diagnosis specific.
2. The medical staff must approve the “order set.”
3. The order set may have no choices within the set for staff to interpret.
4. There can be no therapeutic duplication such as two orders for the same indication unless both medications are to be used.