Medications not yet evaluated by P&T are considered NON-FORMULARY . . . . . Always check 2 unique patient identifiers - NAME and DATE OF BIRTH - at every step! . . . . . Please be sure to document all clinical activities daily.

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10/25/19 dc Could TJC be here Monday?
October 25, 2019

From: "David Collette" <david.collette@hhsys.org>
To: "Pharmacy" <grp_pharmacy@hhsys.org>
Sent: Friday, October 25, 2019 8:53:55 AM
Subject: Could TJC be here Monday?

Yes, Monday 10/28 is the start of an open week for a TJC survey....we believe there is a good chance they will be here. What can you do today, this weekend, and into next week???
  • Central staff - make sure everything is in order...take a look around the entire area and perform a clean sweep
  • UB/Clin specs - review profiles completely and remove all duplicate PRNs, route mis-matches, and other issues; visit your units and perform a clean sweep (including sharps, crash cart, med prep area, refrig)
  • Julie/Emily - please visit procedural areas and make sure that all is in order
We should know a little after 7:30 am Monday if there is a Code-J. You will then have about 2-3 hours to make sure that everything is ready before they start surveying. Please visit your assigned nursing units, making sure that the med prep and storage areas are in survey-ready shape. Also, scan profiles for duplicate PRNs and other issues. I have attached our Code-J sheets for central, inpatient nursing areas, and outpt/procedural areas. Please use these to prepare and especially each day that the surveyors are here.
 
Thanks for your attention to these matters and for your help is keeping us survey-ready. And, HAPPY PHARMACY WEEK!






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