JCAHO Approves Interim Provisions to Medication Management Standard 4.10
JCAHO has approved interim provisions for Medication Management Standard 4.10 (Element of Performance 1) for critical access hospitals and hospitals.
The ACR and JCAHO have been discussing this standard, which requires pharmacist review of all orders for IV contrast unless a licensed independent practitioner (LIP) controls the ordering, preparation, and administration of the medication.
JCAHO has consistently stated that the LIP (radiologist) must remain with the patient during administration of contrast unless a pharmacist has previously reviewed the order. In conference calls with JCAHO staff, ACR members outlined their serious concerns about this requirement, including potentially severe interruption of work flow, as well as a lack of physicians and pharmacists to meet this requirement.
Additionally, ACR members provided documentation on contrast reactions and the relative safety of contrast media used for imaging exams today.
A hospital’s radiology services (including hospital-associated ambulatory radiology) will be allowed to define, through protocol or policy, the role of the LIP in directly supervising a patient during and after IV contrast is administered. This protocol/policy must be approved by the medical staff, and the role of the LIP is to be defined so that the LIP can intervene in a timely manner in the event of a patient emergency.
JCAHO recommends that organizations refer to the ACR Practice Guideline for Use of Intravascular Contrast Media (2006) while developing their the protocol or policy.