Medication Management Hot Spots

Accreditation standards that can challenge ASCs BY SAHELY MUKERJI

W hen The Joint Commission

looked at the 10 most challeng- ing accreditation guidelines for ASCs in 2016, it found that three of the 10 were related to medication management. “The most challenging standards in the Medication Management (MM) chapter of the accreditation manual include MM 03.01.01, which requires organizations to safely store its medi- cations; MM.01.01.03, which requires organizations to secure medications that are high-alert or hazardous; and MM.01.02.01, which requires orga- nizations to address the use of look- alike and sound-alike medications,” says Joyce Webb, RN, project director in the Standards and Survey Methods department at The Joint Commission in Oak Brook Terrace, Illinois.

Challenging Areas Storing Medications “Many medications have to be refrig- erated, so it is important for ASCs to designate staff to monitor the tem- perature at which the medications are stored,” Webb says. “This means the storing refrigerator needs to have a thermometer and someone needs to regularly check its readings. When the ASC is closed, ideally, a computer is connected to the refrigerator ther- mometer so that during after hours, someone can be alerted in case of power outages.” Even when ASCs routinely monitor the temperature, surveyors often find that the logs ASCs use to document the temperature checks are missing or incomplete, Webb says. “Staff really


need to check the thermometer and document each reading. If they find that the thermometer reading is outside of the recommended safety range, they need to have a process to determine if medication stored in the refrigerator can still be used,” she says. ASCs need to make certain they

know which medications need to be refrigerated,

says Gary Brownstein,

MD, president-elect and chairman of Accreditation and Education Com- mittee at American Association for Accreditation of Ambulatory Surgery Facilities (AAASF) in Gurnee, Illinois. “It will tell you on the bottle, or check with the manufacturer on how to store the product,” he says. “Never store food in the same refrigerator where you store your medications. This is a contamination risk.”

Secure storage of medications can pose additional challenges. “Surgery centers that lock their medications up need to keep the keys to that storage

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