CMS’s New Hospital COPs: Safe Opioid Use, IV Medication, Blood and Medication Administration

Why Should You Attend:

This program will discuss the revised standards on the CMS hospital CoPs on safe opioid use, IV medication and blood transfusion. This is the fifth time this section has been amended in the past few years along with an amendment last to nursing section 405 which addresses safe injection practices, compounding and beyond use date. The following are also covered: CDC opioid guidelines, Joint Commission final pain management guidelines, federal guidelines for opioid programs, opioid epidemic, and required hospital policies and training.

In the survey memo CMS states that while this section is in the nursing section, hospitals are expected to meet the related requirements found in the pharmacy and quality assessment and performance improvement sections. This program will also discuss the ISMP IV Push guidelines for adults which hospital should have. It will discuss the National Action Plan for ADR prevention related to the opioid recommendations. The CMS final worksheet on QAPI will be covered regarding the tracking of medication administration errors and adverse drug reactions. The CDC final opioid guidelines are also discussed.

Areas Covered in the Webinar:

• Introduction into the CMS hospital CoPs
• Where to locate a copy
• CMS deficiency reports and problematic standards for tags in CMS Medication Memo
• How to get apprised of changes
• Changes and safe injection practices
• ISMP 26 pages of guidelines on IV Push medication
• CDC Opioid Guidelines 2016
• Federal guidelines for opioid programs
• TJC pain management guidelines effective in 2018
• Amends tags 405, 409, 412 and 957
• Changes: medication administration, IV, blood, and opioid safe use and immediate post-op care
• National Action Plan for ADE prevention
• Anticoagulants, opioids, and diabetic agents
• Stages of the medication process
• Incidence of medication errors and ADEs
• Reminder for nurses to know pharmacy CoPs
• Blue boxes or advisories
• IV Medication and Blood transfusions
• Guidance on vascular access route
• Verification of tubing connections
• Monitoring patients for fluid and electrolyte imbalance
• Patient risk assessment
• Monitoring to prevent over-sedation of opioids
• Required policy and procedure
• Required nursing education
• Equipment, ETCO2, pulse ox, etc,
• Administration of blood and blood procedures
• Competence of staff
• Assessment and safe use of opioids
• Educating patients and families of side effects
• PCA as a variant of self-administration
• Monitoring post-op patients
• Orders for drugs and biologicals
• Must include many things include age and weight of patient and dose calculations when applicable
• Standing order
• Consistent with state and federal law
• Accepted standards of practice
• Medical staff approved P&Ps
• Basic safe practices for medication administration
• Flu and Pneumovac
• Nine rights
• Timing of medication
• 3 time frames
• Missed or late administration
• Critical and non-critical scheduled medications
• P&P required
• Required education
• Assessment and monitoring of patients
• Documentation requirements
• Audit the nursing documentation

Who Will Benefit:

• Chief Nursing Officer
• Nurse Managers
• Nurse Supervisors
• Nurse Educator
• HIM staff
• Compliance Officer
• Chief of Medical Staff
• Medical Staff Coordinator
• Risk Manager
• Patient Safety Officer
• Documentation Specialist
• Hospital Legal Counsel
• PI Director
• Joint Commission Coordinator
• Regulatory Officers
• Chief Operating Officer
• Chief Medical Officer
• Physicians
• Education Department Staff
• Board Members
• Director of Health Information Management
• Audit Staff
• Others responsible for compliance with hospital regulations including documentation compliance

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

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