April 13, 2007, 3:02 pm

Oh, HELL No!


If ever I needed a good shot of Bromo Seltzer it is now.

My nerves need soothing.

My head is pounding.

I have an acute case of acid reflux.

My blood pressure is sky high.

I’m not sick.

I did however, receive an email from the Emergency Nurses Association.

If you have ever considered joining ENA, now is the time.

They are on our side.

Somebody has to be.

JCAHO has finally crossed the line.


I present to you the latest in Stupid JCAHO Tricks, as described in an email sent to all ENA members.

On April 6, the Joint Commission rescinded the Interim Action for Standard MM.4.10 EP 1 for Emergency Departments. Therefore, in accordance with MM.4.10 EP 1:

“…prior to dispensing, removal from floor stock, or removal from an automated storage and distribution device, a prospective pharmacy review is expected for all medication orders unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.”

Translation: before you are even allowed to remove a medication from your Pyxis or take down a bottle of medication from the shelf in your ER, the pharmacy has to review the order. Except when the resulting delay would hurt the patient.

JCAHO acknowledges the delay!

Am I missing something here?

Never mind the effect on already impacted emergency departments.

Never mind that the only “licensed independent practitioner” in an ED is the physician (or maybe a nurse practitioner or physican’s assistant). They will now have to “control” the ordering, preparation and administration of all medications the pharmacy can’t review.

I hate to be the one to break this to JCAHO, but some hospitals don’t have the luxury of a twenty-four hour pharmacy.


Never mind all those pain medications you order for patients with chronic back problems or migraines.

  • You can’t touch that dial on the Pyxis until you are given permission by the pharmacy.

What about the patients that come in with a single-spaced 81/2 by 11 medication list that must be transcribed?

  • Better write up that medication reconciliation form STAT, because the pharmacy won’t take the patient’s list. You have to fax them the official list for review. In my facility we asked if we could just copy the patient’s sheet and attach that to the form. Apparently this will occur about the same time as pigs begin to fly (I’m paraphrasing).

What if the pharmacy does not recommend giving the ordered drug (for whatever reason) and the doctor disagrees?

  • Can the ED staff still give the ordered drug?
  • Can the pharmacist actually override the physician’s ability to prescribe a specific drug?

How long before we have to fill out a special form to document an “urgent” situation if we do give medication before the review?


JCAHO, you told us we had to put locks on all the doors and we did. We thought it was stupid, but we did it.

Then you told us there must be a medication reconciliation form and almost every hospital I know of put the onus of this on the emergency room nurses. We think it is asinine. But we do it.

You told us we had ask about and document cultural beliefs on the chart. Every single patient I ask looks at me like, “What the heck are you asking?”. That mandate was useless. But we do it.


JCAHO, you may say “JUMP!” and the hospitals will say “How high, Master?” but the emergency departments will not.

The Emergency Nurses Association is in partnership with the American Academy of Emergency Medicine (AAEM) and the American College of Emergency Physicians (ACEP) to oppose this accreditation standard and this mandate will not stand.

Make no mistake. We will fight this with every fiber of our being.

Hell hath no fury like that of the nursing profession when pushed to the brink. And this time we and the doctors are of one mind, one opinion.

JCAHO, you are in danger of becoming a joke.

Your standards are ludicrous.

Enough is freaking enough.


  • Steve

    April 14, 2007 at 2:00 pm

    Oh I don’t think they are in any danger of becoming a joke. They crossed rthat line a long time ago. Keep up the good fight. We on the ER MD side will as well. This sucks. Steve

  • atyourcervix

    April 14, 2007 at 6:22 pm

    JCAHO is such a pain in the arse. I work in L&D, and we have to pull drugs out of the pyxis much faster than the pharmacy can add it to the patient’s profile. Oh, you’re having pain, and want that stadol? So sorry, but the pharmacy hasn’t added it to your profile yet, even though I faxed the order down as soon as your physician wrote it.

    Right now, we can still override many drugs, but that will soon come to an end. I dread that day.

  • Tdoc

    April 14, 2007 at 7:47 pm

    Once again it is proven. The function of a burocracy is only to ensure it’s own survival. Usually this involves reducing an originally good idea to an absurdity.

  • UP Nurse

    April 14, 2007 at 8:01 pm

    I read that e-mail from ENA and almost could not believe it!!! I wonder if anyone from JCAHO ever worked in an emergency department…or even a hospital. We do not have a 24/7 pharmacy…or even pyxis here (and it is a 100 bed hospital).
    Having also worked within the Federal system, both as a civilian and in the military, I have to agree with Tdoc…about the function of a burocracy.
    Unrealistic expectations on the nursing staff, since pharmacy nor physicians are going to do this, will probably make the work environment even worse and folks will leave for somewhere or something else.

  • beastarzmom

    April 14, 2007 at 8:27 pm

    Amen, Kim.

  • Mary Lu

    April 15, 2007 at 1:06 am

    Kimmypoo– Dr. Doug’s pharmacy is not 24/7. Hell his hospital’s too cheap to even lease the pyxis machines he needs to maintain the last round of controls JCAHO has demanded. To top it off, at night you’d have a hell of a time getting one of the on-call pharmacists to even get back to ED or anyone quickly enough. I just printed out the article from the EM Docs and laid it on his snoring chest. He’s not going to be thrilled when he reads this one. Mary Lu

  • NurseWilliam

    April 15, 2007 at 4:43 am

    JCAHO must DIE.

  • faded

    April 15, 2007 at 6:30 am

    I work in the facility management business. We have some hospitals among out clients. The facility managers (FM’s) complain bitterly about JCAHO. Many of their requirements are ridiculous and niggling time wasters. JCAHO is really a major distraction when it comes to running the facility.

    I have come to realize that many of the regulatory requirements are there for JCAHO’s inspection convenience They want to check electronic records and verify that the records are correct. They assume that if the records are correct the actions of the hospital are correct.

    Also many of the requirements I have read are clearly imagined into existence by folks who are separated from the hospitals they regulate. It is clear the folks at JCAHO have way to much time on their hands.

  • NPs Save Lives

    April 15, 2007 at 7:58 am

    JCAHO is getting to be a powerhungry monster. It’s more and more about the paperwork than the patient.

  • Fallen Angels

    April 15, 2007 at 9:49 am

    *sigh* I’m not even in nursing school yet and I can see how utterly ridiculous this is! Diabetes education is looking better and better.

  • geena

    April 15, 2007 at 11:12 am

    Our hospital requires that the pharmacist approve the drug before it is added to the patient’s profile. It was a bit to get used to, but the pharm has caught some mistakes, interactions, etc that might not have been noticed.

    We were extremely annoyed with it at first and sometimes still are, but all of our emergency drugs are still available. In disagreements with the docs, the pharm usually wins, although sometimes the doc sticks to his/her guns and it all works out in the end without any animosity.

    Truly, in my own opinion, of all the asinine rules that have been bought down on us by JointComm, this isn’t the worst.

    I guess we’ve just gotten used to having to wait to give a drug. It’s frustrating to get an order and not be able to give it right away; you have to remember to come back and find out if it’s been verified yet.

    Ok, I get your point. I guess we’ve just gotten used to the insanity.

  • medrecgal

    April 15, 2007 at 12:05 pm

    Ahhh…JCAHO. The bane of any healthcare worker’s existence. I think that was second most common reference in my HIM/medical records curriculum, only after HIPAA. I have always been of the mind that our healthcare system needs some CPR because it’s badly broken and far too bureaucratic to have much chance of giving appropriate and adequate patient care much of the time. The JCAHO regs are just another symptom of this problem. Like they think the pharmacists are the only ones who know how to read a medication order? Give me a break! Just another way to complicate patient care, AFAIC.

    Patients could very well die or suffer other untoward consequences from medication delays imposed by this silly rule, but I guess those up in their bureaucratic ivory towers don’t really care about the patient as long as their rules are followed. That’s what’s really wrong with our system. There are so many laws, rules, and regulations involved these days (and I saw a great number of them along my path to certification) that it’s a wonder anyone can do or say anything without fear of error, retribution, or litigation. Not a pretty picture.

  • may

    April 15, 2007 at 2:44 pm

    i suggest they pay a pharmacist that will man the ER 24/7 so this will at least look like they are serious….

  • Signout

    April 16, 2007 at 2:33 am

    I’m with you on this, Kim–the requirements JCAHO is placing on all hospital departments are thoroughly unreasonable in their demands on administrative and nursing staff. The only potentially good result of this (from my perspective) is that JCAHO’s demands support arguments in favor of a national database of patient health information–which in turn, would go hand in hand with a nationalized health care insurance system.

    Think of the error reduction, the ease of communication, the benefit to patients!

    Probably not in our lifetime, but it’s a nice thought.

    Oh, and by the way–in our hospital, the med rec is the admitting intern’s job. Yay!

  • girlvet

    April 16, 2007 at 11:42 am

    How will this new rule manifest itself? If you have computerized charting will it be checked in the pharmacy and then somehow released in the pyxis so you can give it? Sometimes I think it is already being done in our hospital because I have had a couple of calls from pharmacy about meds. Explain practical implications someone please…

  • Labor Nurse

    April 16, 2007 at 12:12 pm

    JCAHO is always dead on finding the most inconvenient recommendations, aren’t they? We recently were reminded of this as well in our L&D, where we constantly pull meds from the Pyxis without faxing an order to the pharmacy for review. Do you think that I am going to wait around for Narcan to appear on the profile meds when a baby needs it? I don’t think so.

    They other thing that isn’t being taken into account is the time it takes for the pharmacy to actually get around to entering meds into the patients profile. At least at my hospital!

  • jennifer

    April 16, 2007 at 2:21 pm

    ok, kim…i figured out how to post this in the comments.
    as a pharmacist, i have one point i’d like to clafiry with you. i hate JCAHO as much as the next guy, and think the standards are completely asinine, but when you ask Can the pharmacist actually override the physician’s ability to prescribe a specific drug?
    yes, we can and we do…not for JCAHO, but because that’s our job. i will not EVER dispense something that i know will harm a patient, no matter how much a doc or a nurse wants me to. that’s what the hospital pays me to do.

    to agree, though, drug review and med rec in the ER is a BAD BAD idea…it will torture both pharmacy and ER depts and make patient care impossible.

    to some of the other commmentors…no, i don’t think pharmacists are the only ones who can read a medication order, but it is our job and expertise to do so, correctly.
    to the two posters who remarked to the effect of “when the pharmacy gets around to entering orders”…i noticed you are both L&D nurses…yes, i know your patients are in pain and have needs..but don’t you realize that maybe we, the pharmacy, may have sicker patients to take care of than your [essentially] healthy L&D patients…giving birth is not an illness. sometimes our time is taken up by the ICU and, as i am sure you know well, the NICU

  • michelle

    April 18, 2007 at 10:17 am

    I can not belive that JACHO is at it again. We would not have made it had those rules been in place here in Iraq. At night we have no pharmacy. It is a shame that someone who is obviously so far removed from nursing has the ability to put out standards. It reminds me of the 0-6 and above that make a decision that effects the hospital,yet the last time they even sawa a patient was ten years ago. And you are right we all should be members of ENA. I am. Ciao

  • beajerry

    April 19, 2007 at 7:07 am

    Aren’t all patients in the ER subject to “situations in which the patient experiences a sudden change in clinical status”?

    At least I’d chart it that way. 😉

  • ICUCharge

    April 29, 2007 at 4:24 am

    Sometimes the pharmacy has TOO much control over who can and cannot have medications. What has happened to our healthcare system?

    Dump JCAHO…..that should be our new motto.

  • POC

    May 22, 2007 at 12:31 pm

    What about this?
    Kenneth G. Hermann, a hospital consultant for Joint Commission Resources Inc., a JCAHO subsidiary, described to session attendees the other exception:

    “You don’t need to review the orders when a physician is directly involved in the supervision of the care,” he said. “In the emergency department or in surgery,” he explained, “we would not expect the pharmacist to be reviewing that [medication] order.”



  • Joe RX

    April 7, 2008 at 10:29 am

    It’s done because nurses like to play doctor…
    It is esential that orders be reviwed by a Pharmacist ( unless it is a life threatining emergency).
    Nurses need to stick to their scope of practice, period.

    Oh, and they also need to treat their co-workers better,and stop stealing medications!

  • 10mgiv

    October 5, 2008 at 4:36 pm

    Lets invite the JACHO ( * )’s to the ER with a Kidney Stone and let them wait for the Dilaudid.
    Hummmm. Sorry, I need a list of all your current meds. You say you don’t have any, I really don’t believe that, you have pill bottles in your pocket. NOW don’t say:’no meds” thinking you will get your medication for pain faster. the Pharmacist is a little backed up, with surgery and everything you know. You will get your pain med in about 1 hour.
    Nurse Florence Said sooo sweetly…. you made your bed lay in it.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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