As of January 1, all compounding pharmacies are eligible to enroll in The Joint Commission’s new Medication Compounding Certification (MCC) program, including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:
- Ensure pharmacies are compliant with United States Pharmacopeial Convention (USP) and Joint Commission standards
- Reduce the risk and harm stemming from drug compounding
- Uncover and fix problems in existing compounding policies and procedures
- Train personnel on the correct use of PPE and aseptic techniques
- Ensure the physical environment meets guidelines for cleaning and documentation
- Ensure the proper labeling, dating, and sterility of compounded products
In the March edition of The Joint Commission’s Perspectives, the accreditor writes that the program was created in part as a response to national outbreaks from contaminated compounded medicines. The Joint Commission has eligibility requirements and free 90-day access to the MCC standards on its website and in the E-dition® of the Medication Compounding Certification Manual. Their website also will be updated with a list of U.S. states that require compliance with USP General Chapter <795> and USP General Chapter <797>. The MCC standards have also been updated to reflect USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings which was reported on previously in the Patient Safety Monitor Journal.
For more information on the certification contact either:
Hospital-based pharmacies: Brian R. Johnson, 630-792-5144 or firstname.lastname@example.org.
Home care pharmacies: Cynthia Cook, 630-792-5121 or email@example.com
The Joint Commission has updated Sentinel Event Alert, Issue 45: Preventing Violence in the Health Care Setting with new resources:
- Workplace Violence Prevention Resources Portal
- Quick Safety Issue 4: Preparing for active shooter situations, July 2014
- Quick Safety Issue 5: Preventing violent and criminal events, August 2014
In related news, The American Society for Healthcare Risk Management (ASHRM) has released multiple toolkits on how to assess workplace violence risks in healthcare settings. The toolkits also provide guidance and checklists on what to do if violence breaks out and how to protect staff. The toolkits cover five main areas:
- Staff-to-staff violence/harassment
- Physician- or third-party professional-to-staff violence/harassment
- Patient-to-staff violence
- Visitor/family-to-staff violence
- Stranger/nonemployee-to-staff violence
Read Briefings on Accreditation and Quality for more on workplace violence protection.
The Joint Commission has announced additional revisions to its Environment of Care (EC) and Life Safety (LS) chapters. The revisions are meant to bring the accreditor in closer alignment with the National Fire Protection Association’s 2012 Life Safety Code® (LSC). The LSC was adopted by CMS and The Joint Commission last year. The revisions go into effect July 1, 2017 and apply to hospitals, critical access hospitals, ambulatory healthcare centers, home care, and nursing care centers.
Date: Tuesday, January, 24, 2017 1:00–2:30 p.m. EST
Summary: After much anticipation, CMS has approved its own emergency preparedness rules separate from The Joint Commission and other accreditation agencies. Hospitals and healthcare organizations now have until November 15, 2017 to enact the changes and maintain compliance.
Join expert speakers Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, and Thomas Huser, MS, CHSP, CHEP, as they guide you through the changes. They will help you identify resources for implementation, provide helpful tips, outline the special focus on fire drills for critical access hospitals, and list the optional and required CMS emergency management standard categories.
- The list of required and optional categories of the CMS emergency management regulations
- The tips, resources, and potential challenges to implementing an emergency prep plan
- How to conduct fire drills for critical access hospitals
Registration: To order the webcast on demand, call HCPro customer service at 800-650-6787 or visit hcmarketplace.com