New official interpretation of JC standard bans open access to pharmacy after hours

Standard TX.3.5.4 in the Hospital Accreditation Standards of the Joint Commission (JC) states: "Pharmacy services are available when the pharmacy is closed or otherwise unavailable." In describing the intent of this standard, JC notes that, "to deliver consistent quality during all hours of service, the organization must have a safe means of providing pharmacy services when the on-site pharmacy is closed or not available." Earlier this month in an official interpretation of this standard by the Issues and Resolution Committee, JC determined that "open access to the pharmacy is neither safe, nor does it provide a consistent level of quality." This information will appear on the JC web site in the near future as one of the FAQs (Frequently Asked Questions), which serve as official interpretations of existing standards for JC surveyors and hospitals to follow. The official interpretation of this standard will be in effect for surveys performed on or after July 1, 2001.

ISMP fully supports JC in this action. Over the years, we have received too many tragic reports about serious medication errors related to non-pharmacist staff retrieving incorrect medications or doses from a closed hospital pharmacy. This recent official interpretation of the preexisting standard requires hospitals to deliver a consistent quality of pharmaceutical services during all hours and to establish a safe mechanism for obtaining medications after hours if the on-site pharmacy is closed. While non-pharmacist entry into the pharmacy is no longer an acceptable alternative, the use of an outside pharmacy, nighttime floor stock in automated or non-automated dispensing cabinets, and access to a physically isolated part of the pharmacy should be considered when allowed by state law and regulation.

These approaches allow for availability of a limited supply of specific medications for use after the pharmacy is closed. To determine nighttime supplies of drugs which must be given before the pharmacy reopens, review a one-year list of medications previously removed from the pharmacy after hours. Whenever possible, provide premixed solutions and unit dose packaging. Minimize therapeutic duplication and stock nighttime cabinets with the smallest quantity of medications necessary to meet patient needs when the pharmacy is closed. Carefully consider error potential, place alert notices on drug containers as needed and include appropriate drug references near supplies. Provide a list of medications available after hours to all prescribers and gain their support for using these medications whenever possible after the pharmacy is closed. A pharmacist may be on-call for items too risky to store in the nighttime supplies. According to JC, only a limited number of staff (e.g., night nursing supervisor) should be allowed access to the medications available after the pharmacy is closed. These individuals must be appropriately trained and oriented to the nighttime medications and their storage/retrieval, or other approaches used to provide medications after the pharmacy is closed (e.g., outside pharmacy service). There also should be a double-check in place to ensure that the proper drug was selected and removed from the nighttime supplies before administration.

We congratulate JC for taking a strong stance on this issue. While on-site 24-hour pharmacy service may not be an option for all hospitals, careful planning to establish a safe mechanism to provide medications when the pharmacy is closed is essential and cannot be achieved by allowing open access to the pharmacy by non-pharmacy staff