Download The Storage, Distribution, and Administration of

AARC Management Section Guidance Document
The Storage, Distribution, and Administration of
Respiratory Medications
November 2004
Introduction
The management section of the American Association for Respiratory Care
(AARC) developed this guidance document to address issues about compliance
with medication management standards that have been identified by
respiratory therapy managers in acute care hospitals. To optimize patient
safety, the AARC has a responsibility to provide guidance to those developing
policies and procedures to address the storage, handling, distribution and
administration of respiratory medications commonly administered by
respiratory therapists. This guidance document, which has been reviewed by
the JCAHO’s Standards Interpretation Group, is intended to serve as a
reference to assure that policies and procedures implemented are in
compliance with the JCAHO’s current medication standards.
AARC Management Section
Karen Stewart, MS, RRT Management Section Chair
Richard Ford, BS, RRT, FAARC, Management Section Chair-Elect
Bill Farnham, AS, RRT, Management Section Member
Bill Dubbs, MHA, MEd, RRT FAARC-AARC staff
Table of Contents
Topic
Introduction
Review of 2005 JCAHO Medication Standards of Specific
Interest to Respiratory Therapy Managers
Systems for Managing of Respiratory Medications by
Respiratory Therapists
Appendix: Crosswalk of 2003 Standards for Hospitals to
2004 Medication Management Standards for Hospitals
Page(s)
2
3-6
7
8
JCAHO Standards Interpretation Group (SIG) Contact Information:
JCAHO Standards and Interpretation Group
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
630-792-5900 (voice)
630-892-5942 (fax)
Online Standards Submission Form is located on www. JCAHO.org at:
http://www.jcaho.org/Onlineform/OnLineForm.asp
Page 2 of 8
Review of 2005 JCAHO Medication Standards of Specific Interest to
Respiratory Therapy Managers
The medication standards identified in the right cells of following table require
special attention by respiratory therapy managers. The statements in the
corresponding left cells provide guidance to assure and suggest activities to
assure the intent of the standard is met.
JCAHO Mediation Standard
MM 2.20 Medications are properly
and safely stored throughout the
hospital.
CMS definition of “secured” states
that all medications including nonprescription medications are in
locked container in a room or are
under constant surveillance.




MM 4.70 Medications dispensed by
the organization are retrieved and
disposed of when recalled or
discontinued by the manufacturer
or the Food and Drug
Administration for safety reasons


Guidance Statements
Respiratory care departments
must assure that all
medications are in a locked
container or under constant
surveillance.
Policies and procedures for
storing, handling and
distributing respiratory
medications should be similar to
all others in the organization
(e.g. nursing).
While policies and procedures
for procurement and
distribution of medications
should be consistent within the
organization, systems utilized to
properly and safely store
medications may include
automated dispensers as well as
other manual systems in which
medications can be secured,
controlled, and administered.
Medications with names that
sound alike and or have similar
packaging should be segregated.
Medications that are expired,
damaged or are contaminated
should be segregated and
returned to the pharmacy.
Policies/systems should be in
place to identify medications
that have been recalled by the
manufacture or FDA and
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MM 2.30 Emergency medications
and or supplies (if any) are
consistently available, controlled
and secured in the organization’s
patient care areas.
MM 3.20 Medication orders are
written clearly and transcribed
accurately.
MM 4.10 All prescriptions or
medication orders are reviewed for
appropriateness.
remove them from storage and
prevent further distribution and
use.
 Leadership of the organization
with input from the medical
staff determines which
emergency medications are
available in patient care areas.
 Respiratory care medications
which are deemed emergency
medications are available in unit
doses, age specific, and ready to
administer forms whenever
possible. Emergency
medications must meet the
storage requirements as defined
by CMS.
 The respiratory care department
must assure that all elements
are complete in the medication
order. There must be a process
for verbal orders that include a
read back to the Licensed
Independent Practitioner (LIP)
ordering the medication.
 A procedure is required to
address any medication orders
that are incomplete, illegible or
not clear.
A pharmacist must review all
respiratory medication orders
before the respiratory care
department can administer a
medication unless an LIP control is
present and controls the ordering,
preparation and administration of
medication (e.g. in an emergency
department). In the event that a
patient would be harmed by a delay
or situations arise in which a
patient experiences a rapid change
in clinical status, a medication
deemed emergent as specified in
MM 2.30 can be delivered. In such
situations the review can take place
Page 4 of 8
MM 4.30 Medications are
appropriately labeled.
MM 5.10 Medications are safely
and accurately administered.
retrospectively as specified in the
organizations Medication
Management policy. In cases where
an after hours pharmacy is not
provided, a retrospective review
should take place as soon as the
hospital pharmacy reopens.
 Medications can be stored in
any device such as a plastic bag,
syringe, bottle, or box that can
be labeled and secured in a
manner that it assures the
contents are intact and have not
expired.
 Medications are administered
consistent with the law and
regulations or by hospital policy.
 There is a process to notify the
prescriber in the event of an
adverse drug reaction or medical
error.
 The respiratory therapist shall
verify through visual inspection
that the medication is stable.
 The respiratory therapist will
verify that there is no
contraindication for the
medication.
 The practitioner must verify the
medication is correct, and
validate the drug is given at the
proper time, at the prescribed
dose, and the correct route
through documentation in the
Medication Administration
Record (MAR). The MAR should
include two established patient
identifiers that can be used to
reconcile the identification of the
patient, the physicians order,
and the medication label
 The respiratory therapist will
advise the patient and or family
of any potentially adverse
reactions and will discuss any
Page 5 of 8

MM 5.20 Self-administered
medications are safely and
accurately administered.

MM 6.10 The effects of
medication(s) on patients are
monitored.

unresolved, significant concerns
with the prescriber.
If medication is drawn from
multidose vials, procedures
followed to minimize the
dangers of contamination.
There are procedures in place to
guide safe and accurate
administration of medications
for patients that self-administer.
These procedures should also
include training, supervision
and administration
documentation. There must be a
process in place to verify the
competency of the patient in the
event of self- administration.
The respiratory therapist shall
monitor the effects of the
medication during and after
administration to assure that
the medication therapy is
appropriate and to minimize the
occurrence of adverse events.
Monitoring should address the
patient’s response to
medications, the patient’s own
perceptions about side effects
and the perceived efficacy of the
medication.
Page 6 of 8
Systems for Managing of Respiratory Medications by
Respiratory Therapists
The AARC requested the JCAHO to endorse the following scenarios which represent
what is believed to be the most common approaches to storing and distributing
respiratory medications. However, the JCAHO informed the AARC that their
organization does not endorse any scenarios. Because the AARC has received many
reports of inconsistent standards interpretation by JCAHO surveyors; if you are using
or considering using a system that involves a personal portable carrier (fanny pack) as
mentioned in scenario 1 and 2 below, the AARC advises that you personally contact
the JCAHO Standards Interpretation Group (see page 2) seeking individual guidance
prior to initiating or continuing such a system. Note that a pharmacist review of the
medication precedes each of these scenarios.
Scenario 1
The respiratory therapist obtains medication from an automated medication
management system (e.g. Pyxis) or from a locked medication cabinet located in the
respiratory care department. The medications obtained are for only the patients
located on various nursing units throughout the hospital assigned to the therapist
during that round of therapy. The medications are secured by either a personal
portable carrier or in a secured locked box in the possession of the therapist until they
are administered to the patient.
Scenario 2
The therapist obtains medications from an automated medication management system
(e.g. Pyxix) or from a locked medication cabinet located on the nursing unit. The
medications obtained are only those patients who are receiving treatments on that
nursing unit during that round of therapy. The medications are secured by either a
personal portable carrier or in a secured locked box in the possession of the therapist
until they are administered to the patient. The therapist does not go to the medication
management system for one medication at a time. This is the same practice as is
commonly practiced by nurses.
Scenario 3
The therapist obtains medications from an individual secured medication storage unit
at or near the bedside of the patient. All patient medications that do not require
refrigeration are stored in this secured area. Both nurses and respiratory therapists
obtain the patient’s needed medications from this location just prior to administration.
Any missing medications are obtained from an automated medication management
system (e.g. Pyxis) or a floor stock secured inventory.
Page 7 of 8
Crosswalk of 2003 Standards for Hospitals to 2004 Medication Management
Standards for Hospitals
To download this document go to the JCAHO web site at:
http://www.jcaho.org/accredited+organizations/hospitals/standards/new+standards/
mm_xwalk_hap.pdf
This crosswalk is designed to show where the 2003 Care of Patients (TX)
standards requirements appear in the new Medication Management (MM)
standards for 2004. The left column (2003 Standards) lists consecutively each
TX standard that is effective as of 2003; a standard appearing in italics in this
column indicates that the standard was previously not scorable. The middle
column, 2004 Standards, indicates the new MM standards that became
effective January 1, 2004. The right column, Comments, identifies what
changes have occurred between the 2003 standards and the 2004 standards.
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