A Pharmacy Quality and Internal Audit Program Promoting Continuous Survey Readiness with Medication Management...

Area of Science:

• Pharmacy Quality Assurance
• Healthcare Accreditation
• Medication Safety

Background:

• Maintaining Joint Commission Medication Management (MM) standards is crucial for accreditation.
• Continuous survey readiness is as vital as episodic compliance demonstrations.
• A structured program is needed to sustain MM standards.

Purpose of the Study:

• To describe a Pharmacy Quality and Internal Audit Program.
• To promote continuous survey readiness for MM standards.
• To achieve sustained compliance with MM standards.

Main Methods:

• Developed a comprehensive MM audit for inpatient, ambulatory, and procedural areas.
• Conducted audits twice annually, involving chart reviews, staff interviews, and practice observations.
• Communicated findings to leadership and used scorecards for performance tracking.

Main Results:

• Achieved consistent compliance (≥ 90%) with most MM standards, including hazardous medications and controlled substances.
• Identified opportunities in high-alert medication awareness, pill cutter use, and therapeutic duplication.
• Corrective actions improved compliance from <50% to ≥90% for high-alert medication awareness.

Conclusions:

• The Pharmacy Quality and Internal Audit Program facilitates performance tracking and deficiency identification.
• Focused corrective actions and mitigation strategies enhance MM standard compliance.
• The program effectively promotes continuous survey readiness and sustained MM compliance.