CONTENT ANALYSIS OF DRUG MANAGEMENT FINDINGS IN HOSPITAL ACCREDITATION SURVEYS

Objectives

The purpose of Health Care Accreditation Standards Drug Management (DM) section is to minimize the risks for patients and workers in all processes including the drug and to ensure that the processes are carried out effectively and efficiently. This study aims to analyze the content of the survey findings of the DM section Assessment Criteria (AC) in hospitals that have undergone accreditation survey and to determine the situations in which non-compliance is detected the most.

Method

In the study, the survey findings in the DM section of the survey reports concerning the survey, re-survey (focus), annual surveys and re-accreditation surveys performed by Türkiye Health Care Quality and Accreditation Institute (TÜSKA) in 14 hospitals from 2018 to January 2023, were used. All the survey findings, which were written as findings for improvement, were reviewed, along with the findings of the decisions of Partially Met (PM), Not Met (NM) and the Met (M) decision regarding the 6 AC’s in the DM section. The findings were read repeatedly by the researchers at different times and the headings related to the content of the findings were determined. After a joint discussion and exchange of ideas with the participation of all researchers, the content of the AC findings in DM section were grouped under 7 headings.

Results

Accreditation Standards DM section consists of a standard, 6 AC and the requirements related to AC. In the study, a total of 33 surveys related to the DM section were reviewed and it was determined that there were findings in 25 surveys. In the review, it was ascertained that the findings related to the decision on the level of satisfying AC were related to more than 1 requirement of AC. Out of 45 findings in total it was found that 8 findings belong to the M decision, 32 to the PM decision and 5 to the NM decision (Table 1). The AC “Precautions should be taken for patient and worker safety during the preparation and administration of drugs” was determined to be the AC including the most findings at all levels of fulfillment.

The content of the AC findings are grouped under 7 headings (Table 2). It was found that the findings of ACs were most associated with Drug Storage, Drug Administration Stock Management and High Alert Drug. It was determined that ACs included findings at all fulfillment levels under the headings of Drug Storage and Drug Demands.

Conclusion

Regarding the AC of the Medication Management chapter examined in the study; It was determined that the most PM decision was made, and the AC related to the preparation and administration of drugs were the criteria that received the most findings at all met levels. It was determined that the contents of the AC findings, which were decided as PM, were mostly related to the institution's drug management structure, stock management, drug storage, drug administration and high-alert drugs. In the correct planning of the drug management process, which has the potential to seriously threaten patient and worker safety, with the effective and efficient use of resources, it is important that the storage and stock management of drugs and the administration of drugs are fundamental issues that need to be addressed. Accreditation standards, whose main goal is to minimize the risks to the patient and the employee in all processes including the drug, and to ensure that the processes are carried out effectively and efficiently, is a critical issue in the success of drug management.