What are the primary recommendations for a clinical pharmacist working under Joint Commission International (JCI) standards to ensure patient safety in medication management?

Primary Recommendations for Clinical Pharmacists Under JCI Standards

Clinical pharmacists working under JCI standards must be directly involved in the entire medication process—from obtaining accurate medication histories and participating in ward rounds to verifying prescriptions at the point of dispensing and monitoring for drug-related problems—as this comprehensive involvement has been proven to reduce medication errors and prevent adverse drug reactions. 1

Core Patient Safety Activities

Medication History and Reconciliation

• Obtain complete medication histories at every transition of care, as pharmacists obtain more accurate medication histories than physicians and 67% of medication histories contain at least one prescription error, with 22% having potential to cause significant patient harm 1
• Document all current medications including prescription drugs, over-the-counter medications, herbal products, and supplements at each clinical encounter 1
• Verify medication adherence by confirming the patient received the prescription, documenting the start date, and ensuring the patient understands administration instructions (with or without food, crushing versus taking whole, safe handling) 1

Prescription Verification and Safety Checks

Before dispensing any medication, the pharmacist must verify:

• Patient identity using two identifiers (name, date of birth, address) at prescription entry and at dispensing 1
• Appropriate diagnosis, documented allergies, correct drug, dose, and directions by reviewing the most recent provider note to validate the treatment plan 1
• Absence of duplicate therapies through comprehensive profile review 1
• Drug interactions actively at each patient encounter, including review of the patient record and direct conversation with the patient about recent medication changes, over-the-counter medications, alternative medicines, and herbal therapies 1

High-Risk Medication Management

• Focus intensive monitoring on hazardous drugs including anticoagulants (warfarin), insulin, diuretics, amiodarone, and propofol, as these well-established medications are persistently associated with prescribing errors despite extensive knowledge about them 1
• For warfarin specifically, monitor PT/INR determinations closely, especially after hospital discharge and whenever other medications (including botanicals) are initiated, discontinued, or taken irregularly, as numerous factors including diet changes, medications, and genetic variations in CYP2C9 and VKORC1 enzymes influence patient response 2
• Never refill medications unless verified with the prescriber and/or prescriber's agent and the patient/caregiver 1

Special Population Considerations

Elderly Patients

• Conduct comprehensive assessments for declining function in all elderly patients, as cognitive impairment, renal insufficiency, dependence on carers, and polypharmacy are major predictors of drug-related hospital admissions 1
• Explore and recommend low-dose regimens for elderly patients, as most substances are usually prescribed in excessively high doses without evidence of long-term benefit in this population 1
• Apply specialized training in geriatric pharmacology to recognize that elderly patients constitute a readily identifiable high-risk group for medication errors 1

Clinical Pharmacy Service Delivery

Ward Round Participation

• Attend medical or surgical post-admission ward rounds to improve drug history documentation, reduce prescribing costs, and prevent adverse drug reactions 1
• Conduct special medication ward rounds as involvement of clinical pharmacists in almost the entire medication process, from dispensing to administration, can reduce medication errors 1
• Provide an extra verification check whenever a pharmaceutical formulation is modified before administration (crushing a capsule for nasogastric tube), entered via an unusual route, or injected into an intravenous line 1

Documentation Requirements

• Document every clinical encounter with a patient in the patient record, preferably using an electronic medical record system 1
• Record all questions posed by the patient regarding therapy in the patient's record 1
• Document adherence assessment including confirmation the patient received the prescription, start date for medication, and verification of understanding 1
• Document monitoring of drug toxicity, laboratory tests, and any prescription, over-the-counter, or herbal medication changes, contacting the provider in a timely manner to address potential problems 1

System-Level Safety Measures

Standardization and Organization

• Implement uniform prescription forms to reduce errors in prescribing and drug dispensing, as transcription is avoided, communication between physicians and nurses is simplified, and feedback control is facilitated 1
• Prohibit verbal prescriptions and permit only a limited number of standardized abbreviations 1
• Standardize crash cart organization across all hospital locations, with medications clearly labeled with name, date, and concentration, and pharmacy department managing drug trays including stocking, tracking, and delivery 3

Error Prevention Strategies

• Apply the five rights rule at every medication administration: right medication, in the right dose, at the right time, via the right route, to the right patient 1
• Use international color coding for syringe labels, administration routes, preparation bags, patient-controlled analgesia devices, medication carts, and storage devices 1
• Implement error-reduction devices and bar-code readers to minimize human error 1
• Establish protocols for preparing and administering medications, limiting the list of medications delivered and avoiding similarities in shape, color, and name 1

Common Pitfalls to Avoid

• Do not assume medication histories are accurate without pharmacist verification, as physician-obtained histories have significantly higher error rates 1
• Do not overlook hazardous settings such as nursing homes, geriatric home care, surgical departments, intensive care units, and ambulatory care, which are more susceptible to medication errors 1
• Do not neglect financial barriers to adherence; assess and document any financial issues affecting adherence and evaluate the need for increased assistance including copay assistance and patient assistance programs 1
• Do not dispense prescriptions before patient education and consent forms have been completed 1
• Do not ignore the absence of the pharmacist at the bedside, where medication errors typically occur due to incidental distraction and suboptimal performance during specialized activities like checking and administering medicines 1

Continuing Professional Development

• Maintain competence in six essential domains: direct patient care, pharmacotherapy knowledge, systems-based care and population health, communication, professionalism, and continuing professional development 4
• Participate in multidisciplinary continuing education regarding risk management and appropriate use of management devices, with preference for simulation-based teaching tools 1
• Commit to ongoing professional development to ensure clinical pharmacy expertise required to provide comprehensive medication management in patient-centered, team-based settings 4