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Medication Selection and Procurement - Managing Medication Shortages

What are The Joint Commission requirements for managing medication shortages?

Any examples are for illustrative purposes only.

Organizations are required to establish a process for communicating medication shortages to Licensed Independent Practitioners (LIP) and staff who participate in medication management (MM.02.01.01). Examples of 'staff' may include those responsible for ordering, preparing, stocking, storing, and administering medications. Each organization determines the most effective means of communicating this information to key constituents.

While not required, organizations may wish to consider several different means of communicating this information.  Examples may include emails, medical staff newsletters, daily staff briefings and huddles, alerts posted in dictation/documentation stations often used by LIPs, medication dispensing stations, etc. Periodic assessment of the effectiveness of the communication process should be conducted to ensure compliance with organizational requirements.

The time frame for receiving notice of medication shortages is often short and preparing for shortages can be time-consuming and difficult. Therefore, advanced planning is crucial.  If the organization intends to automatically substitute medications during times of shortage, organizations are required to develop written medication substitution protocols. Such protocols must be approved by leadership and the medical staff.  The intent of these protocols is to allow for automatic substitutions which would be utilized if the ordering practitioner had not indicated an alternative medication to an individual patient order.  If providers are expected to determine and order an alternative medication or dosage form, then the protocol would not be required.

If the substitution is made to items located in floor stock or crash carts, where an individual might retrieve a product different than what would be typically used, an approved substitution protocol would also be required.  This would apply to substituting: dosage form; route; concentration (strength); or medication.  Staff education should be conducted for those assigned to those areas affected by medication shortages and where the substitution may occur.

To ensure reduction of risk from variations introduced as a result of shortages, compliance with substitution practices should be included when evaluating the effectiveness of all medication management systems (see MM.08.01.01).  One example may be to review medication errors/adverse drug events to determine if a medication shortage was directly or indirectly associated with the event.  The focus of this evaluation would be to identify performance improvement opportunities and implement risk reduction strategies that can be applied to subsequent shortages. Organizations may also find it helpful to develop a safety checklist that addresses each step of medication management systems when dealing with medication shortages.

Additional Resources
Individual State Pharmacy Boards

Manual: Ambulatory
Chapter: Medication Management MM
First published date: September 12, 2017 This Standards FAQ was first published on this date.
This page was last updated on October 27, 2021

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