Medication Reconciliation National Patient Safety Goal to be Reviewed and Refined

Medication errors continue to be one of the most frequent causes of preventable harm in health care. The Joint Commission is committed to helping organizations prevent medication errors, as evidenced by our National Patient Safety Goal on medication reconciliation, which highlights a critical problem that poses significant risk to patients. However, since the Goal on medication reconciliation was instituted in 2005, many organizations have struggled to develop and implement effective and efficient processes to meet the intent of the Goal.

The Joint Commission Accreditation Committee determined that effective January 1, 2009, survey findings on National Patient Safety Goal 8 (Accurately and completely reconcile medications across the continuum of care) will continue to be evaluated during the on-site survey. However, given the difficulties that many organizations are having in meeting the complex requirements of NPSG 8, the Accreditation Committee agreed that The Joint Commission should evaluate and refine the expectations for accredited organizations. While this evaluation is being conducted, survey findings from NPSG 8 will not be factored into the organization’s accreditation decision. In addition, survey findings on NPSG 8 will not generate Requirements for Improvement (RFIs) and will not appear on the accreditation report.

Recognizing that medication reconciliation problems continue to put patients at risk, The Joint Commission expects organizations to continue to address medication reconciliation within their organizations. During the on-site survey, Joint Commission surveyors will evaluate the organization’s medication reconciliation processes, discuss opportunities for improvement, and collect information on the progress organizations are making in meeting NPSG 8.

In 2009, The Joint Commission will evaluate and further refine NPSG 8. As part of this process, The Joint Commission will consult with health care organizations, physicians, pharmacists, nurses, surveyors, and other stakeholders. Through these discussions, an improved NPSG 8 will be crafted that both supports quality and safety of care and can be more readily implemented by the field in 2010.

Source: The Joint Commission

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