Fifteen Common Safe Injection Practice Deficiencies and How Your Consultant Pharmacist Can Help.

Fifteen Common Safe Injection Practice Deficiencies and How Your Consultant Pharmacist Can Help.

Safe injection practices are one of the most commonly cited deficiencies by certification and accreditation agencies.  But there is good news, your consultant pharmacist can help you avoid deficiencies!  Here are the fifteen commonly cited issues and my recommendations for survey success.

Last week I wrote about three ways to avoid survey fireworks.  One of the items I mentioned was safe injection practices. This is one of the most commonly cited areas by certification and accreditation agencies such as Centers for Medicare and Medicaid Services (CMS)Accreditation Association for Ambulatory Health Care (AAAHC), The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and The Joint Commission (TJC).

In the recent release of the 2020 AAAHC Quality Roadmap, the organization noted the standards facilities most commonly struggle to comply with.  When it comes to safe injection practices, the intent of the AAAHC standards are to ensure patient safety by using nationally recognized guidelines to develop policies and procedures related to infection control, cleaning and disinfection, and safe injection practices.

What are the most common safe injection practice deficiencies?

  1. Not following the Centers for Disease Control and Prevention (CDC)Association for Professionals in Infection Control and Epidemiology (APIC), or other requirements adopted as policy.
  2. Not treating a multi-dose medication vial (opened and drawn in a patient treatment area) as a single patient vial.
  3. Opening, dating, and saving multi-dose vials on anesthesia carts for future use.
  4. Splitting of single-dose vials for multiple doses.
  5. Redrawing medication with a used needle and syringe.
  6. Open and undated vials of insulin in refrigerator in patient treatment area.
  7. Not labeling (name, dosage, date, time, person drawing the medication, etc.) medication drawn up prior to the procedure (especially propofol) and carrying the medication in lab coat pocket.
  8. Not immediately using pre-drawn medication, per clinical practice guidelines or manufacturer’s instructions.
  9. Not following organization policy on handling and disposing of expired materials.
  10. Expired medications found on anesthesia cart, emergency cart and in the
  11. Cart includes a drawer full of drugs that are not separated or identified as look-alike/sound alike.
  12. Many different local anesthetics with different names and strengths are mixed and stored together.
  13. No lists developed for sound-alike/look-alike or high alert medications.
  14. A list of look-alike/sound-alike medications exists, however, individual medications not labeled for ease of identification per list/policy.
  15. Look-alike/sound-alike and high alert lists are available and posted in the pharmacy but not in the other locations where medications are stored such as the nursing station and emergency cart.

How your consultant pharmacist can help you achieve survey success:

  1. Policy and procedure: The first step to ensure safe injection practices is to develop and follow policies and procedures that are based on nationally recognized guidelines such as the CDC, APIC and World Health Organization (WHO).  Your consultant pharmacist should be able to guide you in this process.
  2. Drug shortages: The current COVID-19 pandemic is exacerbating the already problematic shortage of critical medications.  As the list of unavailable medications grows, so does the risk of error. Why is that?  Because unavailable drugs requires facilities and practitioners to be creative to ensure continuity of care.  Getting creative might mean ordering a different medication, a different strength of the same medication or perhaps obtaining a compounded version from an outsourcing facility.  Although these may be great ways minimize the impact of shortages on patients, your consultant pharmacist should help you navigate this potentially dangerous territory.  What are some of the dangers? Using a different medication may require formal addition into your formulary along with staff education for proper usage.  Using a different strength also requires education.  Having a different strength available requires additional calculations, which inherently increases risk.  Lastly, multiple strengths may lead to errors in drug selection, especially when the medications may look-alike or sound-alike other medications.  Finally, if you choose to obtain medications via an outsourcing facility, conducting due diligence is necessary.  Start by making sure the facility is a FDA registered 503B outsourcing facility and that it is licensed in your state. Enlist the help of your consultant pharmacist to ensure you are working with a good company.
  3. Consultant pharmacist visits: Do you have a consultant pharmacist who comes in on a set schedule and does a comprehensive assessment of your medication management systems? Did you answer “NO”?  Or did you answer “YES”, but all your consultant pharmacist does is check expired medications, take a quick look at your refrigerator log, and give you a brief one-page report?  You’re missing out on an opportunity to enhance patient safety and increases your odds of a great survey!  Your consultant pharmacist should be expert at providing comprehensive medication management audits. This includes monitoring all systems with audits that extend far beyond product storage and dating (expiration and beyond use dating).  Some of the most critical areas include the use of single and multi-dose vials, as well as proper labeling and storage. Remember: audits should be comprehensive with a focus on medication management and patient safety.  Additionally, your consultant pharmacist should help keep you up to date with changing industry standards, best practices and survey trends.

Are you doing all you can to ensure safe injection practices?  There are many moving parts and regulatory requirements tied to this one topic.  Although being expert at all aspects is difficult and requires specialization, it’s not impossible to accomplish.  Enlist the help of your consultant pharmacist in making your patients safer and your surveyors happier.  If you need help or have questions, reach out and we will guide you in the right direction.

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.


Any health, medical or drug information on the Web Site is for informational purposes only. This information is not intended to be used, and you should not use it, as a substitute for obtaining professional healthcare advice, diagnosis or treatment. You should always seek the advice of your doctor, a pharmacist or other qualified healthcare provider for professional healthcare advice, diagnosis or treatment for any medical condition.
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