Is your facility ready for survey?  As a consultant pharmacist, I work with ambulatory healthcare facilities to continuously guide and support best practices to ensure patients are safer and surveys are easier, and in this blog, I share insights from my years of experience in this field.

Last week, we discussed ten key medication storage and documentation items that are important for ambulatory healthcare facilities to check in order to ensure survey success and to enhance patient care. This week, we’ll focus on ensuring that your healthcare facility’s medication labeling and administration is both optimized for patient safety and ready for survey success.

10 Medication Labeling & Administration Items to Check Off for Survey Success

1. Multi-dose vials (MDVs): Current guidelines continue to advise facilities to use these vials for single patients whenever possible.  If MDVs are used in patient care areas (such as patient bays, exam rooms, or procedure rooms) they should be discarded immediately after use for that patient.  MDVs used in segregated medication preparation areas can be used until reaching their beyond-use-date.
2. Single-dose vials (SDVs): These vials are always for single use only: they should never be used for multiple patients.
3. Use of propofol: This is a unique single use vial that should only be used for a single patient. Do not save for future cases.
4. Controlled drug wasting: Develop and implement a system to allow proper documentation of all controlled substances, including all discarded doses.  Ensure wasting of controls is carried out by two licensed staff and always done in “real time.”
5. Glass ampules: Always use a filter needle to draw up medications from a glass ampule.
6. Unwrapping syringes:  All syringes should be unwrapped on an as-needed basis and as close as possible to the time of procedure.
7. One-hour rule: Use pre-drawn syringes within one hour of preparation.  The exception to the one-hour rule is when syringes have been properly prepared in a laminar flow hood.
8. The 28-day rule: MDVs that have been opened and used in segregated medication preparation areas away from patient care areas, can be dated with a 28 day beyond-use-date and used accordingly.
9. Reversal agents: Facilities that use agents with available reversals, should also have the reversal agent available.  Examples would be fat emulsion when bupivacaine is used, flumazenil for benzodiazepines and naloxone for opiates.  Staff education is necessary to ensure proper use.
10. Antibiotic timing: Although no longer a G-Code, this is still a good best practice.  Ensure that antibiotics are administered according to current guidelines in relation to the incision time or start of procedure.

The bottom line? If your processes focus on doing the right thing for the patient, your surveys will reflect that. Doing the right thing for the patient, however, requires having the right systems in place to ensure solid oversight of medication management. Though it can be overwhelming, it’s an absolute necessity: a consultant pharmacist can help.

At OctariusRX, we take patient safety seriously. We consult with healthcare facilities and can continuously assess medication practices throughout the year to help avoid survey surprises: if you’re not fully compliant, or you need an expert to provide an independent assessment, please don’t hesitate to contact us.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies  We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.