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From Our Customers: The Top 8 Questions To Expect In Joint Commission Inspections

Posted by Rpharmy Marketing on Jan 14, 2021 9:28:31 AM
Though some Joint Commission inspections have been delayed due to the soaring cases of COVID-19 limiting outside vendors inside hospitals, they are coming. To help you prepare, we’ve surveyed many of our customers and put together a list of the most common questions asked during inspections.

  1. Do You Have A High Alert List And Can Users Easily Access It?

    The Joint Commission requires that high-alert and hazardous medications used in a facility are identified in writing to prevent potential errors and improve patient and healthcare worker safety. This list also must be available to all nurses, doctors, pharmacy staff, and others who come into contact or administer these drugs.
  2. Are Hazardous Drug Protocols Documented And Accessible?
    Typically, USP <800> hazardous drugs (HD) protocols are accessed by nurses, doctors, pharmacy staff, and others through hard and digital copies of the drug information provided by a facility’s pharmacy director, risk compliance department, and other stakeholders. These copies are kept on an intranet, multiple spreadsheets, and documents, as well as binders with printed information.


    These documents contain vital information to protect your staff when storing, prepping, transporting, administering, and disposing of HDs, and must be accessible by all staff that comes into contact with hazardous materials - from the doctor treating the patient to the nurse administering them and the staff disposing of the drugs and other waste. 
  1. Do You Have A Look-Alike Sound-Alike (LASA) List And Where Is It Located?
    When confused these drugs can lead to harmful errors. The Joint Commission requires facilities to create and make available a list of LASA drugs based on those used within a specific facility. 
  1. Are Safety Data Sheets Containing Required Information Available? 
    Previously known as the Medical Safety Data Sheet (MSDS), Safety Data Sheets (SDS) provide written or printed information on hazardous chemicals.


    The Joint Commission requires SDSs to communicate HD transportation requirements and each hazardous chemical used. They also must be available to each healthcare worker on each shift and in every workspace. 
  1. Are Policies and Procedures In Place to Ensure Healthcare Worker Safety?
    An absolutely vital part of your HD program is a specific plan to protect your staff when handling HDs. It must include how HDs are labeled with their identity and warnings; safety data sheets (SDS) for each hazardous chemical; training for healthcare workers working with HDs and SDSs must be available to all staff in their workspaces.
  1. Do Required Facilities Have An Antibiotic Stewardship Program?
    In 2017, the Joint Commission established an antibiotic stewardship standard for hospitals, critical access hospitals, nursing care centers, ambulatory care organizations, and office-based surgery practices. As part of the Commission’s Medication Management Standard, the goal is to enlist hospitals in the prevention of antibiotic resistance. The specific requirements can be found in the MM.09.01.01
  1. How Is Your Facility Conducting Medication Reconciliation?
    One of the newest Joint Commission guidelines results from the complexity created by an increase in patients taking multiple medications. In Medication Reconciliation, clinicians are asked to make “a good faith effort” to collect information from patients about the medication(s) they are currently taking and then reconcile with those that have been newly prescribed. They should then make necessary changes to medication or treatment for the safety of the patient.


    The Joint Commission acknowledges the difficulty of this task saying that centralized databases for prescribing and collecting medication information can make the process more effective.
  2. Is Employee Training and Assessment Documented?
    According to the USP <800> guidelines, employees must be trained according to their specific job function. They also must demonstrate competency prior to handling HDs independently, before working with a new HD or new equipment, and before a change to processes or procedures. Competency must be documented and assessed every 12 months. 

As you know well, this is just a starting point for Joint Commission accreditation, but every little bit helps to ensure you are prepared when your facility is due for inspection. If you have questions about what to expect in your 2021 inspection, contact us here and we’ll be glad to help. 

For more information on what to expect during USP <800> inspections, check out our blog “The Human Cost of Not Going Beyond USP <800> Compliance.” 

Topics: USP <800>

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