Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
Robust document control and workflow management software solution
Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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MCN Healthcare has been indispensable to our accreditation compliance efforts. With Policy Manager, Policy Library and StayAlert!, we have peace of mind that our policies will always be up-to-date and easy to locate.
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Helpful MCN Healthcare Resources
Teva Parenteral Medicines issued a voluntary recall of eight lots of Adrucil (fluorouracil injection, USP) 5 g/100 mL (50 mg/mL) due to the potential presence of particulate matter identified as aggregate of silicone rubber pieces from a filler diaphragm and fluorouracil crystals. Administration of an intravenous product with particulate matter has the potential to result in inflammation, allergic reactions, or blockage of blood vessels, leading to tissue death, which may be life-threatening if vital organs are affected.
Adrucil Injection is used in the palliative management of carcinoma of the colon, rectum, breast, stomach and pancreas and is packaged in pharmacy bulk packages. Package descriptions:
- The pharmacy bulk package has five 5g/100ml vials per shelf pack.
- Individual Adrucil 5g/100 ml vials have the NDC code 0703-3019-11
- The pharmacy shelf pack has the NDC code 0703-3019-12
- The Adrucil 5g/100 ml vial can be further identified by the statement on the label in red that states "PHARMACY BULK PACKAGE NOT FOR DIRECT INFUSION".
Adrucil 5g/100 ml vials were distributed in the United States. Teva has distributed this product through the normal distribution chain of wholesalers, retailers, and pharmacies. Anyone with an existing inventory of the recalled lots should stop use and distribution, and quarantine the product immediately. Customers should notify all users in their facility. Customers who have further distributed the recalled product should notify any accounts or additional locations which may have received the recalled product and instruct them if they have redistributed the product to notify their accounts, locations or facilities to the user level.
Consumers should contact their physician or healthcare provider if they have experienced any problems that may be related to taking this drug product.
Teva has notified its direct customers by mail and has issued an Urgent Drug Recall Letter to direct customers. See the press release for a listing of affected lot numbers as well as product images, a link is provided below.
Last October, The Joint Commission announced the addition of a new chapter, Patient Safety Systems, to their 2015 Comprehensive Accreditation Manual for Hospitals (CAMH). According to TJC, this new chapter is intended to assist hospitals to understand how TJC requirements are related to and can be used to enhance patient safety.
TJC recently clarified that the Patient Systems Chapter contains no added standards. The goal of this chapter is to "...educate hospital leadership about the importance of an integrated patient-centered system that aims to improve quality of care and patient safety."
TJC is underscoring the following about the Patient Safety Systems Chapter:
- There are no added standards. The chapter describes how applying existing requirements can enhance patient safety.
- In both the paper version and the E-dition, the chapter is located after the "How to Use this Manual" chapter.
- Any organizations, not just hospitals, can view the new chapter on TJC's website.
Follow the links below for additional information.
Unintended Retention of a Foreign Object Tops Joint Commission List of Most Frequently Reported Sentinel Events in 2014
The Joint Commission recently released its Sentinel Event statistics summary for 2014. Unintended retention of foreign object was reported 112 times between January 1, 2014 and December 31, 2014 making it the most often reported sentinel event for this time period. TJC's root cause analysis identified Leadership issues as the top contributing factor for this Sentinel Event.
According to TJC, "Leadership" encompasses areas including but not limited to:
- Organizational planning
- Organizational culture
- Standardization (e.g., clinical practice guidelines)
Unintended retention of foreign objects can have catastrophic consequences including the need for additional surgery or even death. Best practices to consider for the prevention of unintended retention of foreign body include:
- Using a multidisciplinary team to develop policies and procedures that are applicable to all operative and other invasive procedures.
- Ensuring policies are evidenced based using resources published by organizations such as TJC, the World Health Organization, the American College of Surgeons and the Association of periOperative Nurses, No Thing Left Behind.
- Ensuring policies and procedures address the following topics:
o Standardized Counting Procedure
o Wound Opening and Closing Procedures
o Intra-operative Radiographs
o Effective Communication
o Appropriate Documentation
o Safe Use of Assistive Technologies
Included with today's notice are example policies and procedures related to the prevention of unintended retention of a foreign object.
Featured Policy Library Manuals
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
MCN Healthcare’s Home Health Policy and Procedure Manual provides over 400 policies and procedures addressing administration, emergency management, human resources, medical records, infection control, safety and security, equipment management, medication management, performance improvement, patient rights and responsibilities, waived testing as well as patient care. The Home Health Policy and Procedure Manual is cross referenced to CMS regulations, TJC, ACHC, and CHAP standards.Read more »
The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!Read more »