When enrolled in the EJF Medication Safety Awards Program, your facility is eligible to receive awards from EJF. (See Medication Safety Awards Program for details.) Enrollment is available through qualified EJF partners.
Below is a list of EJF’s medication safety standards. Click on the EJF Seal of Approval logo for a list of solution providers in each category.
- Pharmacy technicians must be PTCB certified by passing their standard exam.
- The facility must meet these basic standards for operating and managing all IV (intravenous) compounding rooms:
- Bar code labeling and scanning capabilities for medications in the pharmacy.
- Facilities must demonstrate that they’re correctly managing and routinely updating their drug formularies to guarantee accuracy.
- This must be verifiable for all equipment requiring formularies, including smart infusion pump, automated IV compounding equipment, etc.
- Pharmacy technician to pharmacist ratios must be at a safe level. For example, we can’t accept one pharmacist supervising 25 techs.
- Prepackaged medications should always be preferred for purchase when available and the practice of compounding of base solutions in the clinical pharmacies are strongly discouraged and should be eliminated whenever possible.
- Facilities encourage pharmacists to routinely round with physician specialists.
- Pharmacists must be included on all discharge teams.
- Patient is weighed as soon as possible on admission and during each appropriate outpatient and emergency department encounter. The facility avoids the use of stated, estimated or historical weight. The patient’s accurate and current weight is communicated effectively and is obvious to the pharmacy in the EMR where this is taken into consideration when measuring medication.
2. Patient Floors:
- Nurse to patient ratios must be at a reasonable level. For example, we can’t accept one nurse having to manage 20 or 25 patients per shift.
- Back-to-back shifts by any clinician are strongly discouraged and the facility must prove to EJF that this is not a standard of the facility. Safe staffing practices translates to fewer medication errors.
- During shift-changes are when many medication errors occur. Part of this problem stems from the hand-off on the part of the clinicians and the sluggishness inherent in updating the EMR (electronic medical records) during the shift change. The facility must prove that it has systems and protocols to battle this problem.
- Sterile caps must be made available on the ports of all IV tubing sets to prevent catheter-related IV bloodstream infections.
3. Operating Room:
- All clinicians participating in a procedure must have the ability to implement a “hard-stop” if they notice something’s out of place.
- Syringes must be labeled with a color code, and information must be included such as the type, date, time, expiration date, at a minimum. This is why EJF strongly recommends or requires that an EJF approved supplier of equipment be utilized for these purposes. Label rolls frequently used by anesthesia are not viewed as appropriate nor are hand-written labels.
- Syringes and corresponding medication vials must also be managed by EJF approved bar code scanning and labeling technology, preferably interfaced to the EMR.
- Proper inventory administration and just-in-time inventory systems must be in place which assure that commonly used medications and compounding materials are always available (ie. Standard bags of saline with .9% sodium chloride etc.) Prepackaged medications should always be preferred for purchase when available and the practice of compounding of base solutions in the clinical pharmacies are strongly discouraged and should be eliminated whenever possible.
- Inspection of the facility’s medication tracking and inventory system management should reveal that with efficiency, accuracy always takes precedence.
- At a minimum, the department heads must have weekly group huddles, where everyone gathers to discuss initiatives, programs, actionable items, issues and “near-misses” (or commonly called “best catches”) are brought to light and those responsible for doing the right thing and bringing it to everyone’s attention so that everyone can learn from the event. It must be evident to EJF that inside the culture of the organization it is engrained that these types of medication near-misses and catches are deserving of rewards and recognition by peers.