Pain Management - Leadership Responsibility for Providing Access to Prescription Drug Monitoring Program (PDMP) databases - LD.04.03.13 EP 6

Please explain what is meant by the requirement that "The hospital facilitates practitioner and pharmacist access to the Prescription Drug Monitoring Program (PDMP) databases". Does this mean that the organization is required to access the PDMP for every patient receiving opioids?

Any examples are for illustrative purposes only.

Facilitating access to the PDMP means that leadership has implemented systems and processes that support both ease of access and consistent access to the PDMP when required.
Examples may include:
  •  Shortcuts on designated computer desktops to the PDMP database
  •  Links from the organization's intranet site and/or electronic health record (EHR)
  •  Staff and practitioner education that includes access to and when the PDMP is to be queried
  •  Demonstration/return demonstration
  •  Periodic monitoring of compliance as defined  
  •  Periodic refreshers with staff, as defined by the organization
  •  Creating prompts in an electronic medical record (when state law requires accessing before hospital discharge )
Each organization determines who is responsible for accessing the PDMP. This may vary based on different patient care settings.

The requirement does NOT apply to patients receiving short term opioid medications DURING the hospital encounter (for example, opioids administered for a day or two following a surgical or invasive procedure).  During survey, compliance with accessing the PDMP may be evaluated during tracer activities, interviews with staff, practitioners, pharmacists, etc.

NOTE: This element of performance is only applicable in states that have a fully functioning Prescription Drug Monitoring Program (PDMP).

R3 Report: Pain assessment and management standards for hospitals
Sentinel Event Alert Issue 49: Safe use of opioids in hospitals

Last updated on May 04, 2020
Manual: Critical Access Hospital
Chapter: Leadership LD

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