Navigating Key

JCI 8th Modifications

Fahad S. Alkhuzaee, PharmD, BCPS, CAHIMS

Medication Safety Officer | Clinical Pharmacist
Certified Associate in Healthcare Information and Management Systems
King Abdullah Medical City in Holy Capital
Glossary
JCI 7th
• Joint Commission International Accreditation Standards for Hospitals, 7th Edition.
• Published on 1 April 2020.
JCI 8th
• Joint Commission International Accreditation Standards for Hospitals, 8th Edition.
• Published on 1 July 2024.
NEW
• New measured elements introduced in 8th version.
• If a similar element was present in the 7th version
it was not considered “NEW”
MODIFIED
• Combined or modified elements from 7th version.
• if the change preserved the original intent without significant alteration
it was not considered “MODIFIED”.
REMOVED
• Element that was removed or moved to other standards.
Effective Date of Standards
• The Joint Commission International Accreditation Standards for
Hospitals, 8th Edition, is effective 1 January 2025:
• 1. For currently accredited hospitals, this is the date by which you now must
be in full compliance with all new and revised standards in the 8th edition.
• 2. For hospitals seeking accreditation for the first time, this is the date after
which all surveys and accreditation decisions will be based on the standards
of the 8th edition. If you apply for survey and are surveyed before 1 January
2025, the survey will assess compliance with the standards of the 7th edition.
Key Changes
• Accreditation Participation Requirements now surveyed as scorable
standards
• New Global Health Impact (GHI) chapter focused on environmental
sustainability
• New Healthcare Technology (HCT) chapter focused on electronic health
records, telehealth, and cybersecurity
• New Patient Safety Chapter and Sentinel Event Policy to promote
nonpunitive approach on patient safety event reporting
• New requirements for establishing and implementing a program for
nuclear medicine safety
• Enhanced requirements for the care of suicidal patients
Key Changes (cont.)
• New and expanded requirements for organ and tissue transplant
programs
• New requirements for care of vulnerable populations
• New requirement regarding disclosure of clinical errors
• Streamlined risk assessment requirements for facility management
and safety
• Enhanced requirements on workplace violence
• Updated infection control requirements on preparedness and
response for epidemiologically significant or novel pathogens in
response to the global experience with the COVID pandemic
International Patient Safety Goals (IPSG)

JCI 7th JCI 8th

Goal 2: Improve Goal 2: Improve

Goal 1: Identify Goal 1: Identify
Effective Effective
Patients Correctly Patients Correctly
Communication Communication

Goal 3: Improve Goal 3: Improve

Goal 4: Ensure Safe Goal 4: Ensure Safe
the Safety of High- the Safety of
Surgery Surgery
Alert Medications Medications

Goal 5: Reduce the Goal 6: Reduce the Goal 5: Reduce the

Risk of Health Risk of Patient Risk of Health
Care–Associated Harm Resulting Care–Associated
Infections from Falls Infections
 The hospital implements a process to
improve the safety of high-alert
medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital identifies in writing • The hospital identifies, in writing,
its list of high-alert medications. its list of high-alert medications.

03.00 03.01 03.02

 The hospital implements a process to
improve the safety of high-alert
medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital develops and • The hospital implements a risk
implements a process for mitigation strategy for reducing
reducing the risk and harm of the risk of harm from high-alert
high-alert medications that is medications that is uniform
uniform throughout the hospital. throughout the hospital and, in
addition, includes tailored
strategies for specific
medications when necessary.

03.00 03.01 03.02

 The hospital implements a process to
improve the safety of high-alert
medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital annually reviews • The hospital reviews and, as
and, as necessary, revises its list necessary, revises its list of
of high-alert medications. high-alert medications
annually at minimum.

03.00 03.01 03.02

 The hospital implements a process to
improve the safety of look-alike/sound-
alike medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital identifies in writing • The hospital identifies, in writing,
its list of look-alike/sound-alike its list of look-alike/sound-alike
medications. medications.

03.00 03.01 03.02

 The hospital implements a process to
improve the safety of look-alike/sound-
alike medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital develops and • The hospital implements a
implements a process for process for managing look-
managing look-alike/sound-alike alike/sound-alike medications
medications that is uniform that is comprehensive and
throughout the hospital. uniform throughout the hospital.

03.00 03.01 03.02

 The hospital implements a process to
improve the safety of look-alike/sound-
alike medications.
JCI 7th (2021) JCI 8th (2025)
• The hospital annually reviews • The hospital reviews and revises,
and, as necessary, revises its list when necessary, its list of look-
of look-alike/sound-alike alike/sound-alike medications
medications. annually at minimum.

03.00 03.01 03.02

 The hospital implements a process to
manage the safe use of concentrated
electrolytes.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• Only qualified and trained • Only qualified and trained

individuals have access to individuals have access to
concentrated electrolytes, and concentrated electrolytes, and
they are clearly labeled with they are labeled with
appropriate warnings and appropriate warnings and
segregated from other segregated from other
medications. medications throughout the
storage and dispensing process.

03.00 03.01 03.02

 The hospital implements a process to
manage the safe use of concentrated
electrolytes.
JCI 7th (2021) JCI 8th (2025)
• The hospital only stores vials of • The hospital only stores vials of
concentrated electrolytes concentrated electrolytes
outside of the pharmacy in outside of the pharmacy for
situations identified in the emergency situations or specific
intent. purposes, and these are clearly
identified in hospital policy.

03.00 03.01 03.02

 The hospital implements a process to
manage the safe use of concentrated
electrolytes.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital performs initial and

ongoing proactive risk
assessments at least annually for
all areas where concentrated
electrolytes are stored.

03.00 03.01 03.02

Medication Management and Use (MMU)
Sections

Organization
Selection and Ordering and
and Storage
Procurement Transcribing
Management

Preparing and
Administration Monitoring
Dispensing
JCI 7th Total 80 Measured Elements

Organization and Management 11 Measured Elements

Selection and Procurement 3 Measured Elements

Storage 16 Measured Elements

Ordering and Transcribing 12 Measured Elements

Preparing and Dispensing 14 Measured Elements

Administration 15 Measured Elements

Monitoring 9 Measured Elements

JCI 8th Total 96 Measured Elements

Organization and Management 13 New

Elements
24 Measured Elements

Selection and Procurement 1 New

Element 4 Measured Elements

Storage 6 Elements
Removed 10 Measured Elements

Ordering and Transcribing 1 New

Element 13 Measured Elements

Preparing and Dispensing 9 New

Elements 23 Measured Elements

Administration 5 Elements
Removed 10 Measured Elements

Monitoring 3 New
Elements 12 Measured Elements
 MMU.
01

Organization and Management

 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025) NEW

• --- • A qualified individual oversees

the medication management
interdisciplinary team
established to develop the
policies and processes for
medication management in the
hospital.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital documents at least • The medication management

one review of the medication interdisciplinary team develops
written policies and a plan for a
management system, addressing uniform medication management
items a) through i) of the intent system that complies with applicable
as appropriate, annually. laws and regulations and includes the
following processes, as applicable:
• Planning • Planning
• Selection and procurement • Selection and procurement
• Storage
• Storage • Ordering
• Ordering • Preparing, dispensing, and distribution
• Preparing and dispensing • Administration
• Administration • Monitoring the effects of medication
• Medication error and adverse event
• Monitoring reporting
• Medication error and adverse • Evaluation
event reporting • Formal processes for management of
medication shortages and substitutions
• Evaluation

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The medication management

interdisciplinary team is defined
in writing and includes, at
minimum, a pharmacist, a
physician, a nurse, an infection
prevention and control
professional, and hospital
leaders.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025)
• All settings, services, and • All settings, services, and
individuals who manage individuals who manage
medication processes are medication processes are
included in the organizational included in the organizational
structure. structure.

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 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025)
• A licensed pharmacist or other • A licensed pharmacist or other
qualified individual directly qualified individual directly
supervises the activities of the supervises the activities of the
pharmacy or pharmaceutical pharmacy or pharmaceutical
service and ensures compliance service and ensures compliance
with applicable laws and with applicable laws and
regulations. regulations.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025)
• The hospital documents at least • The hospital documents at least
one review of the medication one review annually of the
management system, addressing medication management
items a) through i) of the intent system.
as appropriate, annually.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.00
The hospital manages its medication
management processes
JCI 7th (2021) JCI 8th (2025)
• Appropriate sources of drug • Appropriate and updated
information are readily available sources of drug information are
to those involved in medication readily available to those
use. involved in medication use.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital implements a written

program for antimicrobial stewardship
that is based on scientific evidence,
accepted clinical practice guidelines,
and local laws and regulations.
• Documentation indicating that the scope
• Implementation of at least two evidence-
based clinical practice guidelines
• Evaluation of adherence to at least one
of the evidence-based clinical practice
guidelines

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital develops and • The hospital has an

implements a program for interdisciplinary team that
antibiotic stewardship that oversees the antimicrobial
involves infection prevention stewardship program. The
interdisciplinary team is defined
and control professionals, and includes, at minimum, an
physicians, nurses, pharmacists, infection prevention and control
trainees, patients, families, and professional, a physician, a
others. nurse, a pharmacist, and
hospital leaders.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The antimicrobial stewardship

program demonstrates
coordination among all
components of the hospital
responsible for antimicrobial use
and resistance, including but not
limited to the infection prevention
and control program, the quality
and patient safety program, the
medical staff, nursing services, and
pharmacy services.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025)
• The program includes guidelines • The program includes guidelines
for the optimal use of antibiotic for the optimal use of
therapy for treatment of antimicrobial therapy for
infections, including the proper treatment of selected and/or
use of prophylactic antibiotic high-risk infections, including the
therapy. proper use of prophylactic
antimicrobial therapy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• There is a mechanism to oversee • There is a mechanism to oversee

the program for antibiotic the program for antimicrobial
stewardship. stewardship, and the program’s
effectiveness is monitored
according to hospital policy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The antimicrobial stewardship

program collects, analyzes, and
reports data to hospital leaders,
medication interdisciplinary
committee, infection prevention
and control department, quality
improvement department,
pharmacy leaders, all staff, and
other stakeholders per hospital
policy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025)
• The effectiveness of the • The antimicrobial stewardship
antibiotic stewardship program program uses program data to
is monitored. improve performance of
antimicrobial stewardship
activities

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital develops and implements a program
01.01 for the prudent use of antibiotics based on the
principle of antibiotic stewardship.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • Patients and families receive

education on the antimicrobial
stewardship program and on the
appropriate use of
antimicrobials.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital establishes and • The hospital implements a

implements a process for written policy for receiving and
receiving and acting on acting on notifications of
notifications of medication recalled medications, including
recalls.
medications compounded within
• The recall process includes the hospital in which products
medications compounded within that have been recalled have
the hospital in which products
that have been recalled have been used.
been used.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025)

• The process includes identifying, • The policy includes identifying,
retrieving, and returning, or retrieving, and returning, or
safely and properly destroying, safely and properly destroying,
medications recalled by the medications recalled by the
manufacturer, supplier, or manufacturer, supplier, or
regulatory agency. regulatory agency.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital isolates recalled

medications from the rest of the
medication stock to prevent
accidental use or distribution
and clearly labels them as
“Recalled.”

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital notifies patients

who received recalled
medication and provides them
with appropriate guidance.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital has a process to

inform health care providers
about the recall and advise them
on alternative treatments if
necessary.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.02 The hospital has a medication recall system
process.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The process includes

documentation of all actions
taken related to the recall of a
medication, including details
such as the recall notice,
affected lot numbers, actions
taken, communications sent,
and any responses received.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.03 The hospital manages its medication
management processes

JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital establishes and • The hospital establishes and

implements a process for use of implements a written process for
the following:
unopened, expired medications • Identifying, retrieving, and returning
and outdated medications. opened and unopened, expired
medications and outdated
• The hospital establishes and medications
implements a process for the • Using unopened, expired
destruction of medications medications and outdated
medications.
known to be expired or • Destroying medications known to be
outdated. expired or outdated

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.03 The hospital manages its medication
management processes

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital isolates expired

medications from the rest of the
medication stock to prevent
accidental use or distribution
and clearly labels them as
“Expired.”

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
01.03 The hospital manages its medication
management processes

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The process includes

documentation of all actions
taken related to the expired
medication.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
02

Selection and Procurement

 MMU.
02.00 The hospital implements a process for the
selection and procurement of medications

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The interdisciplinary team

collaborates with hospital
leaders to develop criteria for
determining how decisions are
made for which medications are
available for dispensing or
administering.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
02.00 The hospital implements a process for the
selection and procurement of medications

JCI 7th (2021) JCI 8th (2025)

• There is a list of medications by • The list of medications by both
both brand name and generic brand name and generic name,
name, stocked in the hospital or stocked in the hospital or readily
readily available from outside available from contracted
sources, and the list is reviewed services is reviewed annually.
annually.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
02.00 The hospital implements a process for the
selection and procurement of medications

JCI 7th (2021) JCI 8th (2025) MODIFIED

• The process used to develop and • The process used to develop and
monitor the list (unless monitor the list (unless
determined by regulation or an determined by regulation or an
authority outside the hospital) authority outside the hospital) is
includes representation from
health care practitioners developed by the
involved in ordering, dispensing, interdisciplinary team in
administering, and patient- collaboration with hospital
monitoring processes in the leaders.
hospital.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
02.00 The hospital implements a process for the
selection and procurement of medications

JCI 7th (2021) JCI 8th (2025)

• There is a process for obtaining • There is a process for procuring
medications during the night or medications during the
when the pharmacy is closed following:
and for obtaining medications • At night or when the pharmacy is
not stocked or not normally closed
available to the hospital. • When a medication is not on the
formulary, stocked, or readily
available in the hospital

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 MMU.
03

Storage
 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025)

• Medications are stored under • Medications are stored under
conditions suitable for product conditions suitable for product
stability, including medications stability, including medications
stored on individual patient care stored on individual patient care
units and ambulances, as units and ambulances, as
applicable. applicable.

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 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025) MODIFIED

• Controlled substances are • The hospital stores all medications,

accurately accounted for including biologicals and controlled
(scheduled) medications, in a
according to applicable laws and secured area to prevent diversion,
regulations. and locked, as applicable, in
accordance with laws and
regulations.
• These medications are accurately
accounted for according to
applicable laws and regulations.

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 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025)

• There is a process for managing • There is a written process for
medications or products managing medications or
requiring special handling, such products requiring special
as hazardous medications, handling, such as hazardous
radioactive medications, and medications, radioactive
investigational medications. medications, and investigational
medications.

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 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025)

• Medications and chemicals used • Medications and chemicals used
to prepare medications are to prepare medications are
accurately labeled with contents, accurately labeled with contents,
expiration dates, and warnings. expiration dates, and applicable
warnings.

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 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025)

• All medication storage areas, • All medication storage areas,
including medication storage including medication storage
areas on patient care units and areas on patient care units and
ambulances (as applicable), are ambulances (as applicable), are
periodically inspected to ensure periodically inspected to ensure
that medications are stored that medications are stored
properly. properly.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
03.00 Medications are properly and safely stored

JCI 7th (2021) JCI 8th (2025)

• Medications are protected from • Medications are protected from
loss or theft throughout the loss or theft throughout the
hospital. hospital.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. Emergency medications are available, uniformly
03.01 stored, monitored, and secure when stored out of
the pharmacy.
JCI 7th (2021) JCI 8th (2025)
• Emergency medications are • Emergency medications are
immediately available in the immediately available in the
units where they will be needed patient care areas or are readily
or are readily accessible within accessible within the hospital to
the hospital to meet emergency meet emergency needs.
needs.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. Emergency medications are available, uniformly
03.01 stored, monitored, and secure when stored out of
the pharmacy.
JCI 7th (2021) JCI 8th (2025)
• The hospital establishes and • The hospital establishes and
implements a process for how implements a consistent and
emergency medications are uniform written process for how
uniformly stored; maintained; emergency medications are
replaced when used, damaged, stored; maintained; replaced
or out of date; and protected when used, damaged, or out of
from loss or theft. date; and protected from loss or
theft.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. Emergency medications are available, uniformly
03.01 stored, monitored, and secure when stored out of
the pharmacy.
JCI 7th (2021) JCI 8th (2025)
• Access to emergency • Access to emergency
medications does not require a medications shall not require a
specific individual or keys to specific individual or keys to
unlock the emergency cart. unlock the emergency cart.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. Emergency medications are available, uniformly
03.01 stored, monitored, and secure when stored out of
the pharmacy.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital uses a risk-based • The hospital uses a risk-based

approach to identify and
approach, as described in the implement strategies to improve
intent, to identify and the efficiency and accuracy of
implement strategies to improve medication administration during
emergency resuscitation. This
the efficiency and accuracy of approach at minimum includes the
medication administration following:
during emergency resuscitation. • Review of internal data from
previous emergency situations to
assess the availability of emergency
medications
• Review of literature on the subject

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04

Ordering and Transcribing

 MMU.
04.00 The hospital identifies those qualified individuals
permitted to prescribe or to order medications.

JCI 7th (2021) JCI 8th (2025)

• Only those permitted by the • Only those permitted by the
hospital and by relevant hospital and by relevant
licensure, laws, and regulations licensure, laws, and regulations
prescribe or order medications. prescribe or order medications.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04.00 The hospital identifies those qualified individuals
permitted to prescribe or to order medications.

JCI 7th (2021) JCI 8th (2025)

• Individuals permitted to • Individuals permitted to
prescribe and to order prescribe and to order
medications are known to the medications are known to the
pharmaceutical service or others pharmaceutical service or others
who dispense medications. who dispense medications.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital identifies safe prescribing, ordering,
04.01 and transcribing practices and defines the
elements of a complete order or prescription.
JCI 7th (2021) JCI 8th (2025)
• The hospital establishes, • The hospital establishes,
implements, and trains staff on a implements, and trains staff on a
process for the safe prescribing, written process for the safe
ordering, and transcribing of prescribing, ordering, and
medications in the hospital. transcribing of medications in
the hospital.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital identifies safe prescribing, ordering,
04.01 and transcribing practices and defines the
elements of a complete order or prescription.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • A diagnosis, condition, or

indication for use exists for each
medication ordered.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital identifies safe prescribing, ordering,
04.01 and transcribing practices and defines the
elements of a complete order or prescription.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• All orders and prescriptions • All orders and prescriptions

contain the name of the drug, contain the following elements:
the dose, the frequency and • Name of the drug
route of administration, the • Dose
indication for prescribing the • Frequency
medication, and the maximum • Route of administration
dose.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025) MODIFIED

• Additional elements of complete medication • Additional elements of complete medication

orders or prescriptions include at least a) orders or prescriptions include, at minimum,
through g) identified in the intent as the following as appropriate to the order:
appropriate to the order. • Data necessary to accurately identify the patient
• The data necessary to accurately identify the • When generic or brand names are acceptable or
patient required
• When generic or brand names are acceptable or • Specific guidelines for the use of PRN orders
required • Weight-based orders
• Specific guidelines for the use of PRN (pro re • Rates of administration for intravenous infusions
nata, or “as needed”) orders that include
indications for use and detailed directions for • Special orders such as titrating, tapering, or
overlapping orders, such as more than one range orders
medication for pain • Titration orders include the medication name,
• The types of orders that are weight based or medication route, initial rate of infusion
otherwise adjusted, such as for children, frail (dose/unit of time), incremental units to which
elderly, and oncology patients the rate or dose can be increased or decreased,
• The types of orders that are adjusted for how often the rate or dose can be changed, the
therapeutic range; for example, dosages may maximum rate or dose of infusion, and the
need to be updated based on laboratory values objective clinical measure to be used to guide
for specific medications, such as heparin changes.
infusions or phenytoin
• Rates of administration when intravenous
infusions are ordered
• Other special orders such as titrating, tapering,
or range orders

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital develops and • The hospital implements a written

policy that includes the following
implements a process to manage types of medication orders:
special types of orders, such as • As needed (PRN) orders
• Standing orders
emergency, standing, or • Automatic stop orders
automatic stop, and any • Titrating orders
elements unique to such orders. • Taper orders
• Range orders
• Signed and held orders
• Orders for compounded drugs or drug
mixtures not commercially available
• Orders for medication-related devices
(for example, nebulizers, catheters)
• Orders for investigational medications, if
applicable
• Orders for herbal products, if applicable
• Orders for medications at discharge or
transfer

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital develops and • The hospital implements a

implements a process to manage written process to manage the
medication orders that are following medication orders:
incomplete, illegible, or unclear; • Incomplete, illegible, or unclear;
including measures to prevent including measures to prevent
continued occurrence. continued occurrence
• Special types of orders, such as
• The hospital develops and emergency, standing, or automatic
implements a process to manage stop, and any elements unique to
special types of orders, such as such orders
emergency, standing, or • Verbal, telephone, and text
automatic stop, and any medication orders and the
elements unique to such orders. process to verify such orders

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital identifies safe prescribing, ordering,
04.01 and transcribing practices and defines the
elements of a complete order or prescription.
JCI 7th (2021) JCI 8th (2025)
• Medications prescribed or • Medications prescribed or
ordered are documented in the ordered are documented in the
patient’s medical record or patient’s medical record or
inserted into the patient’s inserted into the patient’s
medical record at discharge or medical record at discharge or
transfer. transfer.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04.01 The hospital has a medication reconciliation
process.

JCI 7th (2021) JCI 8th (2025)

• The hospital identifies the • The hospital identifies, in
information needed to reconcile writing, the information needed
current and newly ordered to reconcile current and newly
medications. ordered medications.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04.01 The hospital has a medication reconciliation
process.

JCI 7th (2021) JCI 8th (2025)

• The patient’s medical records • The patient’s medical record
contain a list of current contains a list of current
medications taken prior to medications taken prior to
admission or registration as an admission or registration as an
outpatient, and this information outpatient, and this information
is made available to the patient’s is made available to the patient’s
health care practitioners and the health care practitioners and the
pharmacy as needed. pharmacy as needed.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04.01 The hospital has a medication reconciliation
process.

JCI 7th (2021) JCI 8th (2025)

• Initial medication orders are • Medication reconciliation
compared to the list of includes comparing the initial
medications taken prior to medication orders with the list
admission, according to the of medications taken prior to
hospital’s established process. admission, according to the
hospital’s established process.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
04.01 The hospital has a medication reconciliation
process.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • A medication review is

conducted when there are
changes to the patient’s level of
care, unit, or health care
practitioner service, including
the discharge planning process
for medication management

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05

Preparing and Dispensing

 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025)

• Medication preparation and • Medication preparation and
dispensing adhere to laws, dispensing adhere to laws,
regulations, and professional regulations, and professional
standards of practice. standards of practice.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025)

• Medications are prepared and • Medications are prepared and
dispensed in clean, uncluttered, dispensed in clean, uncluttered,
safe, and functionally separate safe, and functionally separate
areas with appropriate medical areas with appropriate medical
equipment and supplies. equipment and supplies.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025)

• Staff preparing/compounding • Staff preparing/compounding
sterile products/medications are sterile products/medications are
trained and competent in the trained and competent in the
principles of medication principles of medication
preparation and aseptic preparation and aseptic
techniques and are provided techniques and are provided
resources to support the resources to support the
medication preparation process. medication preparation process.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • During preparation, staff visually

inspect the medication for
particulates, discoloration, or
other loss of integrity.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025)

• Guidelines for use of single-use • Guidelines for use of single-use
and multidose vials are and multidose vials are
identified and implemented in identified and implemented in
the medication processes. the medication processes.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.00 Medications are prepared and dispensed in a safe
and clean environment.

JCI 7th (2021) JCI 8th (2025)

• Medications stored, prepared, • Medications stored, prepared,
and dispensed from areas and dispensed from areas
outside the pharmacy (for outside the pharmacy (for
example, patient care wards) example, patient care units)
comply with the same comply with the same
cleanliness measures required in cleanliness measures required in
the pharmacy. the pharmacy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital’s process for radiopharmaceuticals is
05.01 in accordance with laws, regulations, and
guidelines.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital has a written

process to prepare and dispense
radiopharmaceuticals in
accordance with laws and
regulations and clinical practice
guidelines.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital’s process for radiopharmaceuticals is
05.01 in accordance with laws, regulations, and
guidelines.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • Radiopharmaceuticals are

prepared by, or under the
supervision of, an appropriately
trained and qualified individual
(for example, a nuclear
technologist, registered
pharmacist, doctor of medicine
or osteopathy, chemist,
biologist, or qualified nurse).
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital’s process for radiopharmaceuticals is
05.01 in accordance with laws, regulations, and
guidelines.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • Sterile radiopharmaceutical

facilities are designed and
controlled to minimize airborne
contamination, and provide an
appropriately lighted and
comfortable working
environment.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital’s process for radiopharmaceuticals is
05.01 in accordance with laws, regulations, and
guidelines.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • Radiopharmaceuticals are

transported and stored in
accordance with laws and
regulations and guidelines to
maintain their stability and
radioactivity until they are
administered.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital’s process for radiopharmaceuticals is
05.01 in accordance with laws, regulations, and
guidelines.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • Radiopharmaceuticals are

packaged in appropriate
containers, and labeled to
provide the following essential
information:
• Name of the radiopharmaceutical
• Dosage
• Expiration date
• Radiation warning symbol(s)

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025)

• The hospital defines the patient- • The hospital defines, in writing,
specific information required for the patient-specific information
an effective review process, and required for an effective review
the source or availability of this process, and the source or
information is available at all availability of this information is
times when the pharmacy is available at all times when the
open or closed. pharmacy is open or closed.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025)

• Apart from exceptions identified • Each prescription or order is
in the intent, each prescription reviewed for appropriateness in a
or order is reviewed for manner, identified by the hospital,
appropriateness in a manner, that ensures a full appropriateness
identified by the hospital, that review prior to dispensing and
ensures a full appropriateness administration, except in an
review prior to dispensing and emergency or when the ordering
physician is present for ordering,
administration and includes administering, and monitoring of
elements a) through g) in the the patient, in accordance with
intent. laws and regulations.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025)
• Apart from exceptions identified in • The process to conduct an
the intent, each prescription or order appropriateness review for an order
is reviewed for appropriateness in a or prescription prior to dispensing
manner, identified by the hospital, includes evaluation of the following:
that ensures a full appropriateness
review prior to dispensing and • Appropriateness of the drug, dose,
administration and includes elements frequency, and route of administration
a) through g) in the intent. • Therapeutic duplication
• a) the appropriateness of the drug, dose, • Real or potential allergies or sensitivities
frequency, and route of administration; • Real or potential interactions between
• b) therapeutic duplication; the medication and other medications or
• c) real or potential allergies or food
sensitivities; • Variation from hospital criteria for use
• d) real or potential interactions between
the medication and other medications or • Patient’s weight and other physiological
food; information
• e) variation from hospital criteria for use; • Current or potential impact as indicated
• f ) patient’s weight and other by laboratory values
physiological information; and • Other contraindications
• g) other contraindications.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025)

• Individuals permitted to conduct • Individuals permitted to conduct
appropriateness reviews are appropriateness reviews meet
judged competent to do so, are the following criteria:
permitted to do so by privileges • Are assessed competent to do so
or job descriptions, and are by a qualified individual(s).
provided resources to support • Are permitted to do so by
the review process. privileges or job descriptions.
• Are provided resources to support
the review process.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025)

• When the designated licensed • When the designated licensed
professional is not available to perform professional is not available to
the full appropriateness review, a trained perform the full appropriateness
individual conducts and documents a review, a trained individual conducts
review of critical elements h) through k) and documents a review of the
in the intent for the first dose, and a full following critical elements for the first
appropriateness review is conducted
within 24 hours. dose, prior to the full appropriateness
• Allergies review that must be conducted within
• Lethal drug-drug interactions 24 hours:
• Weight-based dosing • Allergies
• Potential organ toxicity (for example, • Lethal drug-drug interactions
administration of potassium-sparing • Weight-based dosing
diuretics in patients with renal failure) • Potential organ toxicity

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025)

• Clinical decision support • Clinical decision support programs
programs used for the full used in conjunction with a
appropriateness review, as well designated licensed professional or
as other computer programs and trained individual for the full
print reference materials used to appropriateness review, as well as
cross-check the critical elements other computer programs and print
reference materials used to cross-
of an appropriateness review, check the critical elements of an
are current and updated. appropriateness review, are current
and updated.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
05.02 Medication prescriptions or orders are reviewed
for appropriateness.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • After the medication order has

been reviewed, concerns, issues,
or questions are clarified with
the individual prescriber before
dispensing according to hospital
policy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. A system is used to safely dispense medications in
05.03 the right dose to the right patient at the right
time.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital dispenses

medications and maintains
records in accordance with laws
and regulations, licensure, and
professional standards of
practice.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. A system is used to safely dispense medications in
05.03 the right dose to the right patient at the right
time.
JCI 7th (2021) JCI 8th (2025)
• Medications are dispensed in • Medications are dispensed in
the most ready-to-administer the most ready-to-administer
form available. form available.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. A system is used to safely dispense medications in
05.03 the right dose to the right patient at the right
time.
JCI 7th (2021) JCI 8th (2025)
• The system supports accurate • The system supports accurate
and timely dispensing and and timely dispensing and
documentation of dispensing documentation of dispensing
practices. practices that meet patient
needs.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. A system is used to safely dispense medications in
05.03 the right dose to the right patient at the right
time.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital has a written policy

for medication labeling practices
that at minimum includes the
following:
• Information on medication labels
• Medications not immediately
administered
• Preparing individualized medications
for multiple patients
• When a patient medication(s) is
prepared by someone other than the
person administering the medication

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. A system is used to safely dispense medications in
05.03 the right dose to the right patient at the right
time.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• After preparation, medications • All medications prepared in the

hospital are correctly labeled with the
not immediately administered following:
are labeled with the name of the • Medication name, strength, and amount
medication, the (if not apparent from the container)
• Expiration date when not used within 24
dosage/concentration, the date hours
prepared, the expiration date, • Expiration date and time when expiration
and two patient identifiers. occurs in less than 24 hours
• The date prepared and the diluent for all
compounded intravenous admixtures and
parenteral nutrition formulas

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
06

Administration
 MMU.
06.00 Medication administration is safely performed by
qualified individuals.

JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital identifies those • Only authorized clinical staff

individuals, by job description or administer medications. The
the privileging process, hospital defines those who are
authorized to administer authorized to administer
medication, with or without
medications. supervision, in accordance with
laws and regulations. The
hospital may place limits, when
appropriate, on the medication
administration of individuals.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
06.00 Medication administration is safely performed by
qualified individuals.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital implements a

process for medication
administration to verify that the
medication is correctly
administered in accordance with
the medication prescription or
order.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 JCI 7th (2021) JCI 8th (2025) MODIFIED

• Medications are verified with • Prior to administration, the individual

administering the medication must do the
the prescription or order. following:
• Verify the identity of the patient.
• Verify that the medication selected
matches the medication order or
prescription and product label, including
time, frequency, dose, and route.
• Visually inspect the medication for
particulates, discoloration, or other loss of
integrity.
• Verify that the medication has not expired.
• Verify that no known contraindications
exist.
• Verify that the medication is being
administered at the proper time, in the
prescribed dose, and by the correct route.
• Discuss unresolved concerns about the
medication with the patient’s physician or
health care practitioner (if different from
the physician or health care practitioner)
and/or staff involved with the patient’s
care, treatment, and services according to
hospital policy.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
06.00 Medication administration is safely performed by
qualified individuals.

JCI 7th (2021) JCI 8th (2025) MODIFIED

• Medications are administered as • Medications are administered as

prescribed on a timely basis and prescribed on a timely basis, and
noted in the patient’s medical each dose is recorded in the
record. patient’s medical record.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
06.00 Medication administration is safely performed by
qualified individuals.

JCI 7th (2021) JCI 8th (2025) MODIFIED

• Patients are informed about the • As appropriate, prior to

medications that they are going administering a new medication,
the patient or family is informed
to be given and have an about any potential clinically
opportunity to ask questions. significant adverse drug reactions
or other concerns regarding
administration of a new medication
and have an opportunity to ask
questions. This education is
documented in the patient’s
medical record.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
06.00 Medication administration is safely performed by
qualified individuals.

JCI 7th (2021) JCI 8th (2025) NEW

• --- • Before administering a

radioactive pharmaceutical for
diagnostic purposes, staff verify
that the dose to be administered
is within 20% of the prescribed
dose, or, if the dose is prescribed
as a range, staff verify that the
dose to be administered is
within the prescribed range.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 Policies and procedures govern medications
MMU.
06.01 brought into the hospital by the patient or family,
medication prescribed for patient self-
administration, and medication samples.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital establishes and • The hospital defines, in writing,

implements a process that when medications brought into
includes a) through e) of the the hospital by patients or their
intent for medications brought families or brought into the
in by the patient/family. hospital as samples can be
• The hospital establishes and administered.
implements a process that
includes a) through e) of the
intent for medication samples.
01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 Policies and procedures govern medications
MMU.
06.01 brought into the hospital by the patient or family,
medication prescribed for patient self-
administration, and medication samples.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital establishes and • If self-administration of

implements a process to govern medications is allowed, the
patient self-administration of hospital follows the written
medications. processes that guide the safe
and accurate self-administration
of medications or the
administration of medications by
a family member. The processes
address training, supervision,
and documentation.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 Policies and procedures govern medications
MMU.
06.01 brought into the hospital by the patient or family,
medication prescribed for patient self-
administration, and medication samples.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital educates patients and

families involved in self-administration
and documents in the patient’s
medical record about the following:
• Medication name, type, and reason for
use
• How to administer the medication,
including process, time, frequency, route,
and dose
• Anticipated actions and potential side
effects of the medication administered
• Monitoring the effects of the medication
• Proper storage of the medication

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 Policies and procedures govern medications
MMU.
06.01 brought into the hospital by the patient or family,
medication prescribed for patient self-
administration, and medication samples.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital determines that the

patient or the family member
who administers the medication
is competent at medication
administration before allowing
them to administer medications.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU.
07

Monitoring
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025) MODIFIED

• Medication effects on patients • The hospital follows a written

are monitored and documented process to monitor, respond to,
when appropriate. and document actual or
• Medication adverse effects on potential adverse drug events,
patients are monitored and and adverse drug reactions.
documented.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital follows a written

process addressing prescriber
notification in the event of
adverse drug events and adverse
drug reactions.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital complies with

internal and external reporting
requirements for actual or
potential adverse drug events
and adverse drug reactions.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025)
• The hospital utilizes a • The hospital uses a standardized
standardized process for process for reporting adverse
reporting adverse medication drug events as part of the
effects as part of the hospital hospital quality and patient
quality program. safety program.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025)
• Adverse effects are reported as • Adverse drug events are
identified by the process in the reported as identified by the
time frame required. process in the time frame
required.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital conducts a root

cause analysis of data when
adverse drug event patterns or
undesirable trends occur.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital monitors and responds to actual or
07.00 potential adverse drug events and adverse drug
reactions.
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital uses the analysis of

adverse drug-related events to
improve medication use
processes.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital implements a process for identifying,
07.01 reporting, managing, and tracking all medication
errors and near miss events (or close calls).
JCI 7th (2021) JCI 8th (2025)
• The hospital establishes a • The hospital adopts definitions
definition for a medication error of a medication error and a near
and near miss. miss from established and
updated guidelines.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital implements a process for identifying,
07.01 reporting, managing, and tracking all medication
errors and near miss events (or close calls).
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital establishes and • The hospital establishes and

implements written processes for the
implements a process for following:
reporting and acting on • Identifying medication errors and near
misses
medication errors and near • Timely reporting of medication errors
and near misses
misses. • Managing medication errors and near
misses, including investigating,
developing an action plan(s), and
following up on the actions over time as
applicable
• Tracking medication errors and near
misses

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital implements a process for identifying,
07.01 reporting, managing, and tracking all medication
errors and near miss events (or close calls).
JCI 7th (2021) JCI 8th (2025) MODIFIED

• Those accountable for acting on • Those accountable for acting

the reports are identified. and following up on the reports
are identified.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital implements a process for identifying,
07.01 reporting, managing, and tracking all medication
errors and near miss events (or close calls).
JCI 7th (2021) JCI 8th (2025) NEW

• --- • The hospital conducts a root

cause analysis of the data when
medication error and near miss
patterns or undesirable trends
occur.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
 MMU. The hospital implements a process for identifying,
07.01 reporting, managing, and tracking all medication
errors and near miss events (or close calls).
JCI 7th (2021) JCI 8th (2025) MODIFIED

• The hospital uses medication • The hospital uses the analysis of

errors and near misses reporting medication errors and near miss
information to improve events to improve medication
medication use processes. use processes.

01.00 01.01 01.02 01.03 02.00 03.00 03.01 04.00 04.01 04.02 05.00 05.01 05.02 05.03 06.00 06.01 07.00 07.01
END OF REVIEW