Medication Overrides

by Jen Cowel

Medication Overrides

by Jen Cowel

by Jen Cowel

How do you handle medication overrides?

There is a new EP 16 for MM.08.01.01. It establishes a policy expectation for medication overrides. It pinpoints the review process for appropriateness and the frequency of the review. TJC also states that 100% review of overrides is not required.

Medication Overrides

But, what do you need? Here are the three steps you should take:

  1. Develop the policy expectation for reviewing overrides
  2. Develop the policy expectation for how often you will analyze this issue
  3. Actually conduct and document your analysis!

Do you perform an end-of-year summary for all the requirements in MM.08.01.01? If so, add this new issue to your analysis summary.

Additionally, all these new requirements take effect 1/1/18. So now is the time to develop the policies and processes. Implement them before year end.

The Clarifications and Expectations column continued in July and August discussing LS.02.01.30, EP’s 1 – 15. In the future, look for a blog post that will discuss EP’s 16-25.

Lastly, share both articles with your facilities leadership team and review this frequently scored standards article. Use it as a focus of rigorous self-assessment.

The Joint Commission boxes each EP inside what they call a “Standards Connection.” Make sure you ask four basic questions about each requirement.

1. Do we do this or do we have this?
2. What evidence do we have that validates we know we do this or have this?
3. What is the re-inspection frequency for this issue that keeps us on top of the requirement?
4. When we conduct our self-assessments, how often do we see zero defects?

In addition, you can get regular updates on new medication standards and other TJC and CMS compliance topics. Subscribe to our newsletter or blog.

Patton Healthcare Consulting assists with Joint Commission compliance assistance, CMS survey support and Joint Commission International Accreditation. Contact us for additional information.


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