We're Having a "Make It Make Sense" Moment.
Recently, a large health system client underwent a Joint Commission inspection. Using heparin as the tracer drug, the inspector asked a nurse to pull up the heparin policy.
Simple enough, right? The nurse opened Epic, navigated to the drug monograph, and clicked through to the latest policy, which had been updated just a few weeks prior. Clean, current, accessible.
Then the inspector asked to see the previous version of the policy, the one that had been replaced three weeks earlier.
The nurse couldn't find it. It had been archived and removed from Epic.
They were cited.
We agree, Ron Burgundy.
Here's where it gets frustrating: the Joint Commission apparently requires that superseded policies remain linked in the EHR, so inspectors can verify that updates were actually made. But from a patient safety standpoint, keeping old policy links visible creates real risk of confusion.
Nurses shouldn't have to pause and confirm whether they're looking at the current version of a high-alert drug policy.
It's long been considered best practice to break the link to outdated policies precisely to prevent that kind of error. And yet, here we are.
When we shared this story with another large health system client, they nodded and said, “Yes, we've been cited for this too, several times.”
To make matters more circular, once a health system has been cited, inspectors return specifically looking for those old policy links. No link? Another citation.
We want to hear from you.
Has the Joint Commission asked you to show archived policy links in your EHR? Have you been cited for this? How did you solve this issue? Email us at info@rpharmy.com. We'd love to know how widespread this issue is, and will share more about how others are solving it.