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Survey Preparedness: Compliance Enhances Safety

A major focus of all CPS pharmacy professionals is compliance with regulatory standards. Whether we’re surveyed by TJC, DNV, HFAP, CIHQ, or CMS, the primary endpoint is to complete the visit with as few citations as possible. This is important for the big picture of accreditation, but what about patient safety? The standards in many cases have an effect on our processes around the safe use of medications, even if it’s not obvious. The most frequently cited TJC medication management standards in 2016 all have implications on safety, as do the corresponding standards from other regulatory bodies.

To listen to a discussion on this topic, please tune in to the CPS podcast on TJC strategies at


  • Proper storage conditions assure that our patients receive their drugs in their intended form, not compromised by temperature or other excursions
  • Robust medication security practices, especially around controlled substances, minimize diversion and the potential for our patients to be treated by impaired caregivers


  • More CPOE should result in an increase in complete and accurate orders or protocols, and pharmacists are well positioned to contribute to this
  • Policies that guide the administration of medications when a therapeutic duplication exists, with a range order, and with missing routes will enhance patient care while streamlining the process for clarification


  • Order review by a pharmacist is considered a cornerstone in patient safety; only in well-defined situations should this crucial step be skipped
  • Areas where pharmacist review may not be happening, but should be, include PACU, Day Surgery, and holding areas for procedural units such as Cath Lab and GI
Posted: Tuesday, June 19, 2018

Tags: Medication Safety, Survey, Regulatory, Blog