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area secure,” Webb says. “And when they remove medications from the stor- age area, they should not leave them unattended. Prescription pads must not be left unattended, either.” This is especially true for medica- tions that are high-alert or hazardous, meaning those that have the poten- tial for causing cancer, developmen- tal or reproductive toxicity, or harm to organs,” Webb says. She cites anti- neoplastic drugs like Heparin, insulin, and potassium chloride as examples of high-alert or hazardous medications. “Sometimes, organizations have difficulty determining which medica- tions fall in the high-alert or hazardous category,” she says. “So, the first step would be to identify the medications they have on hand that fall into this category and then take steps to mini- mize and prevent errors.” Webb recommends that surgery centers visit the Institute for Safe Medication Practices (ISMP) web site and look at its high-alert medi- cations list. Another good resource is the National Institute of Occupational Safety and Health (NIOSH) web site, which also provides a list of high-alert medications. “ASCs can look at these lists and determine which of these medications are in their inventory. Once their list is developed, ASCs need to implement processes to safely store these medications.”


ASCs need to maintain a sequen- tial narcotic inventory and keep a log of their narcotic use in a bound journal or in the computer, Brownstein says. “If it is not bound, it can be tampered with,” he says. “It can also be kept in a computer with password protection, but most people prefer the paper ver- sion as it is easier for the facility per- sonnel to use.” Surgery centers must have pro- cesses in place to prevent the mix-up of look-alike and sound-alike medi- cations, Webb says. “Identify these medications in your inventory by vis-


Avoiding unsafe medication preparation and administration practices in your ASC is largely a function of creating processes and systems and then having the discipline to follow them.”


— Gary Brownstein, MD American Association for Accreditation of Ambulatory Surgery Facilities.


iting the ISMP web site and where they list medications with confusing names,” she says.


Multi-Dose Versus Single-Dose Vials Probably the biggest challenge that ASCs face in adhering to standards is in the use of multi-dose versus single- dose vials, says Jan Davidson, CASC, board member of the Accreditation Association for Ambulatory Health Care (AAAHC) in Skokie, Illinois. “If you draw up a medication in the


patient area, it now becomes single- use,” Brownstein says. “It is no lon- ger multi-use, it is single-use and it must be discarded. If you draw it in a medication area or sterile area where it is kept, you have to label it and store it, and it still remains multi-use. The multi-dose vials have to be outside of the patient care area.”


The Centers for Medicare & Med-


icaid Services (CMS) has designated the following as ‘immediate jeopardy infection control breach’ situations, says Cheryl Pistone, RN, clinical director of ambulatory accreditation at AAAHC: “Using the same needle for more than one individual, [which includes] using the same syringe, pen or injection device (e.g., pre-filled, manufactured, insulin or any other medication or biological) for more than one individual; and re-using a


needle or syringe which has already been used to administer medication or a biological to an individual, to subsequently enter a medication con- tainer (e.g., vial, bag), and then using contents from that medication con- tainer for another individual.”


Other Areas Davidson and Pistone cite the follow- ing as areas where ASCs can falter: “drug shortages; not having a Pyxis for better control of narcotics and other controlled drugs; preparing med- ications and not using them within an hour of their preparation; spiking all the IV bags first thing in the morning for the expected number of patients and then not using them until several hours later; cleaning off IV ports prior to injection; and using one IV saline bag all day for reconstituting antibiot- ics prior to administration.” Brownstein says some anesthe-


siologists prefer to bring their own drug/equipment but surgery centers still must have their own narcotic log. “Typically, the facilities fail to do that and, instead, depend on the anesthesi- ologist to keep a log of the medication. Both have to keep a log.” Undrawn and unlabeled medica- tions in the inventory could be another area of challenge, he adds.


Solutions “Avoiding unsafe medication prepa- ration and administration practices in your ASC is largely a function of cre- ating processes and systems and then having the discipline to follow them,” Brownstein says. Store high-alert or hazardous cat-


egory medications separately from other medications, maybe on a dif- ferent shelf or in a different cabinet, Webb advises. “Label them in a unique way, like applying fluorescent stickers to them, to alert staff.” For look-alike and sound-alike medications, “use special labeling,


ASC FOCUS JUNE/JULY 2017 |www.ascfocus.org 11


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