(Brookfield, WI – January 5, 2018) PharmEcology Services, WM Sustainability Services
According to the standards described below, The Joint Commission will focus on pharmaceutical wastage of controlled substances as well as hazardous pharmaceutical wastage with a focus on applicable diversion prevention strategies. Diversion potential exists from waste containers where partially used syringes and vials of controlled substances and hazardous pharmaceutical waste can be found. Containers must be secured, accounted for and in compliance with legal and regulatory requirements in the patient care areas, procedural areas, and storage areas. Controlled substances must be “…unusable, and unrecoverable” per TJC via deactivation of the specific active pharmaceutical ingredient (API).
The information summarized below was presented by The Joint Commission during the December 2017 American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting in Orlando, FL.
MM.03.01.01 Medication Storage and Security
EP 4: The hospital has a written policy addressing the control of medication between receipt by an individual health care provider and administration of the medication, including safe storage, handling, wastage, security, disposition and return to storage.
Other relevant standards
MM.03.01.01 EP 3: medications stored in secure areas to prevent diversion and locked when necessary
MM.03.01.01 EP 6: prevent unauthorized persons from obtaining medications
MM.05.01.11 EP 2: dispensing practices and record keeping including anti-diversion strategies
To be prepared for an upcoming survey, organizations should pay particular attention to the security and accountability systems of waste and disposal throughout the medication use system; proactively monitor and correct waste and disposal processes and ensure organizational compliance with legal and regulatory requirements.