6th Edition In-Depth: Appropriateness Review
Standard MMU.5.1: Medication prescriptions or orders are reviewed for appropriateness.
New language has been added to the intent and to several of the measurable elements to help clarify the requirements of the appropriateness review.
The goal of an appropriateness review is to improve the quality and safety of adding a new medication to the patient’s treatment plan and reduce the risk of an adverse medication event. The process for the clinical medication review was first defined by Zermansky et al. as “…the process where a health professional reviews the patient, the illness, and the drug treatment...”
The Institute for Healthcare Improvement (IHI) has identified that every medication order should be reviewed by a pharmacist to ensure appropriate selection of drug, dose, route, and frequency as well as to check for interactions with other medications. The Joint Commission International Accreditation Standards for Hospitals, 6th Edition describes a complete appropriateness review in the intent of MMU.5.1 as a review of the order or prescription for the following:
- The appropriateness of the drug, dose, frequency, and route of administration;
- Therapeutic duplication;
- Real or potential allergies or sensitivities;
- Real or potential interactions between the medication and other medications or food;
- Variation from hospital criteria for use;
- Patient’s weight and other physiological information; and
- Other contraindications.
According to the IHI, the complete appropriateness review is performed by clinical pharmacists; however, the JCI standards identify that it is acceptable for other licensed, trained individuals to perform the review when clinical pharmacists are not available. Clinical pharmacists may not be available in some countries for a variety of reasons, for example, there may be a shortage of available clinical pharmacists, or laws and regulations may not recognize the profession. When other licensed individuals perform the appropriateness review, they are considered competent to do so by virtue of education and training, as specified by privileging for licensed independent practitioners or demonstrated competency for nurses or other professionals.
For many organizations, performing the complete appropriateness review during off-hours, such as during the night shift, on weekends, or during holidays, is difficult due to limited availability of clinical pharmacists or the designated trained individuals. The IHI supports developing a process for handling new medication orders placed during off-shifts if pharmacists (or other designated trained reviewers) are not on duty 24 hours a day for the full appropriateness review.
The intent of standard MMU.5.1 identifies a process for handling a new medication order placed during off-shifts that requires a review of four critical elements of the appropriateness review. The four critical elements include:
Lethal drug/drug interactions
Potential organ toxicity (such as administering paracetamol in a patient with liver failure)
Measurable Element 4 identifies that the review of the four critical elements during the times in which trained, designated personnel are not available to perform the full review, can be performed by individuals with documented training in conducting the critical elements of the review and who are supported by reference materials, computer programs, and other resources. The full review is required to be conducted by the designated licensed professional within 24 hours.
In addition, language was added to the intent and to ME 6 requiring that print reference materials as well as computer programs used as part of the appropriateness review process be current and updated.
Zermansky AG. Who controls repeats? Br J Gen Pract 1996; 46: 643–7.