Ambulatory Buzz

Information on all things ambulatory from The Joint Commission

New Medication Management Standards Effective Jan. 1, 2018


By Kelly Podgorny, DNP, RN, Project Director

The Joint Commission’s updated medication management (MM) standards are effective January 1, 2018, for all accredited ambulatory care organizations and office-based surgery practices. The intent of the update is to assure the standards continue to reflect evidence-based practices and quality and patient safety issues that emerged from the healthcare field in recent years. During the review by staff from our Department of Standards and Survey Methods (DSSM) it was determined some additions and revisions were also needed for the Environment of Care [EC] and Record of Care, Treatment, and Services [RC] standards. 

The Joint Commission conducted a field review of all proposed revisions pertaining to medication management during September and October 2016. These final standards changes require organizations to take the following actions:

  • Implement a policy to provide emergency backup for essential medication dispensing equipment identified by the organization
  • Implement a policy to provide emergency backup for essential refrigeration for medications as identified by the organization
  • Add “wasting” of medications to the required written policy addressing the control of medications between when they are received by an individual health care provider and when they are administered
  • Implement a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews when automatic dispensing cabinets are used
  • Record, in the patient’s clinical record, the date and time of any medication administered.

Emergency Back-Up Policies
Essential back-up power is highly relevant for ambulatory settings and is addressed in two separate EPs (see the first two bullets above). Both requirements are found in the EC chapter and mandate that organizations establish a policy to provide emergency back-up for medication dispensing equipment and refrigeration of essential medications. There is no specific direction on the content of the policy, but organizations must document how they will provide emergency back-up for essential medication dispensing equipment and essential refrigeration for medication identified by the organization.

Appropriate Medication Overrides
Ambulatory care organizations also must be aware of MM.08.01.01, regarding the review of overrides. Per the new EP 16 for Standard MM.08.01, the organization must have a policy regarding the type of medication overrides that will be reviewed for appropriateness and frequency of reviews when using automatic dispensing cabinets. Note - a one hundred percent review of overrides is not required. 


Defining “Signed and Held” Orders
Lastly, ambulatory care providers should be familiar with the new type of medication order that was added to the examples in Standard MM.04.01.01, “signed and held orders.” A "signed and held order" is a medication order with specific instructions from a licensed independent practitioner to administer the medication to the patient in a clearly defined circumstance that becomes active upon the release of the order on a specific date(s) and time(s). In the ambulatory care setting, this may apply to patients transferred from ambulatory care to a different setting, who have an order for a medication to be administered upon arrival at the new setting. 

According to Joyce Webb, RN, Ambulatory Care program project lead at the Joint Commission, “These revised and updated medication management standards support the provision of safe and effective medication management in ambulatory care organizations.” 

While these are the most pertinent updates for ambulatory care organizations that reflect the latest evidence based research, more medication management standards are available for all settings.

For more information regarding the new medication management revisions, please contact Kelly Podgorny, DNP, RN, project director, at .