Top 10 Compliance Best Practices for Medication Management

The Medication Management Council formed by Omnicell in 2014 recently issued its Top 10 Compliance Best Practices, which are shared below. The mission of the Medication Management Council is to identify medication management best practices that will move the industry forward.

For 2014-2015, the Council’s goals were to generate top 10 lists of best practices in the areas of safety, efficiency and compliance in the hospital setting.

With a paramount commitment to serve as an open forum for unbiased, objective discussion, the Council comprises primarily non-Omnicell members, most of whom have pharmacy or nursing backgrounds.

The team initially generated a list of over 20 topics related to supporting compliance with a multitude of regulations. After lively discussion, analysis, and research, the list was narrowed to 10 best practices. Hospitals and health systems are encouraged to use the best practice list to assess their own medication practices and determine areas of improvement on which to focus.

“Compliance is obviously a broad area, so the Medication Management Council identified the most impactful best practices, many of which are well-established today, while others are somewhat aspirational,” explained Ken Perez, vice president of healthcare policy for Omnicell. “The Top 10 Compliance Best Practices list gives a hospital an easy way to focus on specific action items to pursue.”

Top 10 Compliance Best Practices for Medication Management

1) Health information systems should maintain and communicate accurate patient information across the continuum of care.

Description: There should be bi-directional information flow between the hospital’s electronic health record and other electronic health records so that all pertinent information regarding patient medications is available to all professionals involved in the delivery of care. This information should be made available to patients through an online portal and/or applications on mobile devices.

2) All electronic devices involved in the medication-use process should have cybersecurity measures in place to prevent outside parties from gaining unauthorized access.

Description: Effective cybersecurity is needed to ensure that medical device functionality, confidentiality, and integrity are maintained. While wireless, Internet- and network-connected devices have improved healthcare, their proliferation has led to greater security and patient safety risks. In addition to potentially harming the patient through incorrect drug dosing, tampering with wireless infusion pumps could expose a healthcare system to malicious attacks, leading to loss of data and services, resulting in downtime and loss of productivity. In order to ensure patient safety, measures—including encryption of wireless networks, laptops, workstations, removable storage media, and mobile devices—must be taken to prevent unauthorized parties from remotely accessing electronic devices involved in the medication dispensing process.

3) Medications should contain tracking methods (barcodes, RFID, etc.) with standardized format and content.

Description: Medication packaging or the process of shipping medications should have methods that support data capture for tracking distribution and transport of medications from manufacturer to the end user and all relevant points in between. Systems should enable the retrieval of specific delivery information in compliance with the Drug Supply Chain Security Act.

4) Healthcare information systems should incorporate tracking methods for all doses at all steps in the medication-use process.

Description: Because medications dispensed to a patient should be of the utmost quality and efficacy, medications should be traceable in order to track expiration dates, facilitate removal when expired or recalled, and prevent introduction of counterfeit medications into the dispensing process. Automation should be able to read all formats, given that the format contains the standardized information (drug name, dose, drug quantity, strength, lot number, expiration date) required by regulation.

5) Medication administration information should be directly retrieved from devices (IV pumps, automated dispensing cabinets, etc.) and transmitted to the electronic health record for appropriate documentation.

Description: The nurse should scan the patient, scan the medication, and associate the IV pump with the medication. Information should then be sent from the medication administration record to the IV pump, and the IV pump should send information back to the electronic health record once the infusion is complete, including the stop time. Finally, the nurse should validate all information in the electronic health record and complete the transaction. This process should enhance billing compliance, as most outpatient infusion requires start and stop times, and it also should help pharmacy batch IVs using real-time data.

6) An analytics system should pull data from disparate sources and provide dashboards and applications that are easy to navigate, intuitive, and efficient, and which feature required regulatory compliance data.

Description: Given the highly regulated nature of the medication-use process, software applications that monitor and measure compliance with regulations should be used.

7) To ensure proactive surveillance of medication use, all orders and dispensing transactions should be reconciled with administration events and readily retrievable.

Description: Data collection of medication delivery and administration should be captured in real time through transactions for dispensing, storage in automated dispensing cabinets and/or administration to the patient. Distribution loops should be closed by matching dispenses from medication storage areas with patient administrations. Open transactions should be shared with those who have the responsibility to monitor medication use for appropriate follow up.

8) Pharmacists should be responsible for initiating, monitoring and discontinuing medication orders, as well as maintaining an accurate medication list.

Description: Pharmacists should have provider status and the ability to maintain patient medication lists across the continuum of care.

9) Interprofessional team member roles related to medication management should be clarified and supported by national regulatory bodies.

Description: Within the interprofessional team, pharmacists should play an integral role in the medication management process. Increased collaboration between all healthcare professionals involved in the management of medications should improve patient outcomes. The respective roles and responsibilities of team members should be outlined in each discipline’s scope of practice regulation.

10) Patient charges should be derived from medication administration data rather than medication dispensing records.

Description: Administration records with bedside electronic confirmation are the most accurate reflection of the medications a patient receives. By generating billing transactions based on these administration events, a hospital should ensure that billing and administration data match, preventing insurance refunds and potential fraud charges for overbilling. In addition, this practice should eliminate the need to manually credit items dispensed but not used, saving time and effort.

Council Expanding its Scope Beyond Acute Care

Thus far, the Medication Management Council has focused on best practices for the acute care setting. But the Council is expanding its scope to the full continuum of care, and has added two members from post-acute care institutions to its roster. For 2016-2017, the Council plans to revise its top 10 lists of best practices in the areas of safety, efficiency and compliance to take into account settings such as retail pharmacy and long-term care, in addition to the acute care hospital.

Have you had experience in carrying out some of the top 10 best practices listed above? If so, feel free to share your successes or challenges in the comments section below.

Read our previous post on the Top 10 Safety Best Practices

Read our previous post on the Top 10 Efficiency Best Practices

2 thoughts on “Top 10 Compliance Best Practices for Medication Management

  1. I can see why it’s important to try and implement all of these practices. Mixing up medications can end up causing a lot of problems. I like practice five about transmitting everything to the electronic health record immediately.


  2. All of the compliance practices, that are listed above, are quite important. Every phase of the drug-supply chain should be done strictly in accordance with the regulations. And that’s why Good Clinical Practice courses should be regularly taken, so organizations from the pharmaceutical or clinical research industry can always be prepared and be familiar with the latest practices.


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