Currently, JCAHO standard MM 4.10 allows hospitals that do not have an on-site pharmacy open 24 hours a day to have qualified health care professionals, such as nurses, review medication orders in the absence of a pharmacist.

However, JCAHO is planning to change the language of MM 4.10 Element of Performance #3 to the following:  “When an on-site licensed pharmacy is not open 24 hours a day, 7 days a week, the organization makes arrangements for a pharmacist review during these hours.”(1) The change to standard MM 4.10 would apply to both Hospitals and Critical Access Hospitals and take effect on January 1, 2006.  This would eliminate the option of having a nurse complete the initial review of a medication order prior to administration with a retrospective review by a pharmacist. Under this new standard, hospitals would be required to assure that a pharmacist reviews all medication orders prior to administration of the medication to a patient. The pharmacist is not required to be on-site in the hospital to complete the order review or supervise the preparation/dispensing of the medication.

(1) Excerpt from the Joint Commission on Accreditation of Healthcare Organizations 2006 Medication Management Standards Field Review on JCAHO.org.