Some of the most common deficiencies in recent surveys are directly related to medication management and safety. How does your facility oversee pharmaceutical services and patient safety to avoid survey deficiencies? Let our pharmacy consultants help you.

Each year the Accreditation Association for Ambulatory Health Care (AAAHC) releases their Quality Roadmap, a report on accreditation survey results. As we analyze the report and compare it to previous versions, one thing becomes apparent…we have made some improvements, but we are still struggling with many areas related to safe medication management.

Although the deficiencies vary slightly between surveys that are Medicare Deemed-Status and those who are not, they are similar. Below is a list of the most common deficiencies, what surveyors are finding/citing and some suggestions to avoid them. For a complete list, please refer to the complete contents of the AAAHC Quality Roadmap.

1. Medication reconciliation:

Here are some common findings by surveyors:

Medication reconciliation not performed or performed sporadically;
No single source medication reconciliation form used resulting in inconsistencies;
No newly prescribed medications listed;
No discontinuation of medications recorded and/or included in patient instructions;
No resumption of medications in patient instructions or on the reconciliation form;
Medication reconciliation does not include any OTC and/or herbal supplements;
No discharge instructions regarding the dose, strength, and frequencies of the discharge medication;
No form provided to the patient upon discharge; and
No documentation or documentation was inconsistent with patient discharge instructions.

How can you maximize survey compliance?

Determine one consistent method for documenting medications and incorporate it into your organization’s policies, procedures, and staff training. Also, consider using one consistent form for medication reconciliation that the patient reviews and receives upon discharge.

2. Allergy documentation:

Here are some common findings by surveyors:

Allergies are documented but no specific reaction information recorded;
Allergies, sensitivities, and reactions not consistently updated at every visit;
Inconsistent use of “NKDA” and “NKA”;
Form designated for allergies and sensitivities is not consistently utilized for verification at each visit;
Presence of allergies, sensitivities and reactions is not noted in a prominent and consistently defined location;
Allergy information (when evident) was frequently found in multiple locations. Some of the locations had part of the information while others had other pieces;
No evidence that “NKA” designation included allergies to both drugs and other materials (e.g., supplements, herbs, environmental factors, food); and
Inconsistent allergic reaction documentation (e.g., nurse’s note and anesthesia record did not match).

How can you maximize survey compliance?

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.

3. Safe injection practices:

The list of safe injection findings by surveyors is long enough to be the subject of a completely separate post. Below is a small sample of commonly cited items and a few ways to avoid them.

Not treating a multi-dose medication opened and drawn in a patient treatment area as a single dose vial;
Opening, dating, and saving multi-dose vials on anesthesia carts, OR, and PACU for future use, as opposed to keeping MDV in a designated clean area away from patient care or treating the MDV as an SDV because it has been in an unclean patient care area;
Not sterilizing medication vial stopper before drawing the medication;
Not labeling (e.g., name, dosage, date, time, person drawing the medication) medication drawn up prior to the procedure (especially propofol);
The disposal policy for narcotics directed staff to flush medications;
No list of confused drug names at the facility or not specific to drugs on their formulary;
High alert medications list is incomplete and marking of medications with red stickers does not align with the medication list; and
A list of confused drug name medications exists, however, individual medications not labeled for ease of identification per list/policy.

How can you maximize survey compliance?

Observe and enforce safe injection practice guidelines especially with multi-dose vial storage/administration and syringe labeling in procedure rooms or other patient care areas. Properly label all medications and use designated and approved expired medication disposal methods (do not flush or dispose in regular waste). When it comes to high-alert medications and those with confused names (Look-alike-sound-alike), it is imperative that you have proper lists posted and that those lists be specific to your facility. Develop a policy on identifying and labeling these medications to avoid mishaps, as well as deficiencies.

All the items listed above are frequent flyers on licensing and certification surveys and your pharmacy consultant should be expert in helping you avoid them. Although this list comes from the 2021 AAAHC Quality Roadmap, these safety issues are relevant to patient safety no matter the organization performing the survey. The task of maintaining all these items in full compliance can be overwhelming, but it’s something we take seriously and are passionate about. If you aren’t working with a pharmacy consultant who is expert in safe medication management and regulatory compliance in the ASC setting, we recommend you do so. If you have questions about this post or need additional guidance, please reach out to 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.