Medication management and infection control are the most commonly cited areas during surveys. Do you know what the most targeted areas are? How do you ensure your facility is always prepared for survey? Survey readiness requires ongoing effort and expertise. Do you have a plan? In this post we will discuss some of the most common deficiencies and ways to avoid them.
It’s not a big surprise to see medication management and infection control at the top of the deficiency list. Each of these categories seem fairly straightforward on paper, but once you start peeling back the layers, it turns out these are extremely large onions. Even though infection control and medication management may be individual chapters in a book of standards, the reason for the complexity is because they are inextricably woven throughout most of the other standards. There are items that are strictly infection control, others that are strictly medication management and many that are both. There are even items that at first look don’t appear to belong in either category, but actually do.
Let’s look at a few examples:
Allergy documentation: In a previous post titled “Some of the most common deficiencies in recent ASC surveys”, we discussed how this is an often-cited standard for various reasons. There’s more to allergy documentation than just noting that a patient is allergic to a particular medication. Among the requirements are that the allergy be noted and further clarified with the specific reaction of the patient. Allergies should be prominently and consistently located in the chart and updated with each visit. As you have probably guessed by now, this standard is very much related to medication management.
Multi-Dose vials: Would this fall under medication management or infection control or both? The obvious answer is medication management, right? That’s partially correct. Although usually medication related, the use of multi-dose vials requires strict adherence to infection control protocols. The specific requirements are a topic that we could dedicate an entire discussion to. In general, multi-dose vials can be very problematic when proper infection control procedures are not followed. Improper use has led to outbreaks of bloodborne pathogens and associated infections, including hepatitis B and C virus.
Having a policy to address recalled medications: This is a requirement that at first glance seems to be strictly medication management, but it is one of the infection prevention and control standards in the Accreditation Association for Ambulatory Health Care (AAAHC) accreditation handbook. Does your facility have a policy and procedure for recalled medications? Does it include vaccines, blood and blood products, medical devices, equipment and supplies, and food products? For full compliance with this standard, it should.
Identifying and labeling high-alert medications and those with confused names (look-alike-sound-alike): It is a requirement that your facility’s inventory be monitored for the presence of high-alert medications and medications with confused drug names. These medications are often involved in errors that lead to patient harm. Do you have a plan in place to manage them? Have you created and posted your list? How are you highlighting these medications when stored, to minimize errors? How do you manage additions and removals from your formulary? How are medications handled during administration? How do you handle sample medications? Are your lists reviewed and updated annually?
When it comes to patient safety and regulatory compliance, what can you do?
Now that we’ve identified some common areas of deficiency, what are some ways to improve practices to enhance patient safety and ultimately make your survey successful and go smoothly?
Allergy documentation: Determine one consistent method for documenting allergies and incorporate it into your policies, procedures, and staff training. Have a specific place to record the reaction next to the listing of allergies. Train your staff on all allergy documentation requirements and review frequently. Your pharmacy consultant should be able to assess your process and give you additional guidance upon reviewing your charts.
Multi-dose vials: 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.
Having a policy to address recalled medications: The obvious first step is that you must have a policy. If you don’t already have one, your pharmacy consultant should be able to help you develop one. If you still need help or would like our policy, please reach out to us. The second part required to maintain compliance is making sure your staff knows the policy and is following it. Many times, facilities are cited for a deficiency even though they have a policy…the policy may be great, but it doesn’t matter if your staff is not following it.
High alert medications: High alert medications require special attention, and a consultant pharmacist can help ensure this happens. Some tips? Post the most recent list and ensure your staff is continuously educated on the contents of the list. Use warning labels for both ‘Look-Alike-Sound-Alike’ and ‘High-Alert Medications’. If the labels on the shelf are bent, frayed or in hard to read, replace them with fresh, clear versions. The Institute for Safe Medication Practices (ISMP) is a great resource for obtaining a current list of high-alert medications.
Look-Alike-Sound-Alike Medications (Confused Drug Names): These medications require special safeguards to reduce the risk of errors and avoid patient harm. A consultant pharmacist can help to make sure you’ve established, and are following, best practices. Some tips? Post your organization’s ‘Look-Alike-Sound-Alike’ list for all staff members to see and refer to, and make sure the list is specific to the medications currently used at your facility. If formulary changes are made, the list should be updated too. You can develop your list based on the Institute for Safe Medication Practices (ISMP) List of Confused Drug Names.
In this post we barely scratched the surface on infection control and medication management requirements and deficiencies. They are complex topics with many moving parts. If you are interested in additional details, or if you’d like to discuss something we didn’t quite get to in this post, don’t hesitate to reach out.
If you already work with an expert pharmacy consultant, they should be updating you on these topics frequently to keep your staff continuously prepared for the next survey. If you are not working with someone who has extensive knowledge in these areas or lacks the depth to ensure licensing and accreditation success, consider doing so. Working with any consultant is an investment. Working with a pharmacy consultant is not just a matter of checking off a box…Pay for someone who is excellent and make sure you are getting value in return for your time and cost.
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.