Q&A: Noncompliance with Medication Management (MM.04.01.01 EP 13)

Q: At our facility, we were found noncompliant with MM.04.01.01 EP 13, requiring a hospital to implement medication order policies. What actions should we take to correct this?

A: If this EP were found to be noncompliant, an action might be to blitz staff members involved in taking telephone orders with mailers, education, memos, email blasts, posts, and newsletters. Actions taken should be focused on the failed portion of the policy only. A policy revision isn’t expected, unless the organization determines that a change is needed. The title of the leader who has approved the correction process needs to be documented. Submission would be within 45 days.

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