In this week’s post, we are discussing three things to do now to avoid deficiencies in the new year. There are always additional tasks to be completed and our work is never done, but there are items we take for granted that have a large impact on patient safety and survey success. Here are three items you should review to make sure you end the year on a good note and begin the new year strong.

1. Formulary Review: I didn’t say the list was going to be exciting, but this is a critical requirement for every ambulatory surgery center (ASC). It should be an annual ritual to review and revise the facility formulary and the end of the year is a great time to get it done. Speak with each of the providers in your center and determine if adjustments are needed. Is there a new medication on the market that is more effective than the one currently on the formulary? Maybe a drug shortage has caused your practice to pivot and start using an alternate therapy. Maybe there’s something in the code cart that is no longer necessary. Once the decision has been made to make a change, document the rationale, present it to the governing body, receive sign off and implement it. It’s surprisingly easy, but you’d be amazed at how many facilities fail to do this correctly. What happens when you don’t execute it correctly? That’s right, a potential citation during survey by licensing or accrediting organizations, such as the 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). Best way to avoid these deficiencies is to develop a system and follow it consistently. Don’t forget to lean on your pharmacy consultant. If you’re working with a good one, he or she should be able to constantly guide you through any changes you need to make.
2. Policy and procedure Review: Yet another topic no one enjoys and for good reason! Policy and procedure development is not a fun activity. It’s also not particularly hard, but it does take skill. You want your policies to address the issue at hand, but you also want to be careful to not paint yourself into a corner. There are two big reasons facilities get into trouble with policies. The first is because they developed a policy that is too restrictive and complying with it is very difficult, if not impossible. The second reason is developing a policy that is not reflective of their actual practice. The most important part of policy and procedure development is to make sure it outlines what is being done by your staff. A policy that is not being followed is a roadmap for a deficiency. Policies and procedures should be simple, clear, and easy to follow.
3. Look-alike-sound-alike and high-alert medications (LASA): Speaking of policy and procedure, do you have one that addresses medications with confused names (look-alike-sound-alike) and high-alert medications? This is a standard that is often cited and requires expertise to navigate correctly. Medication management, overall, can be an overwhelming process and is more than a full-time job. We recommend you work with a qualified and specialized pharmacy consultant to help steer you through this process. If you work with the right one, the value you receive in terms of patient safety, reduced liability, and regulatory compliance, far outweighs the cost. When it comes to LASA and high alert medications, they are often involved in errors that lead to patient harm and there are steps you can take to safeguard your patients. Once your policy and procedure is developed, you will need to create a list that is specific to your facility. We provide a customizable list to each of our facilities on an annual basis, but you can create your own. If you’re creating your own list and not working with a pharmacy consultant, who is reviewing and updating this list annually? The list should be prominently posted in areas where medications are used. How are you highlighting these medications when stored, to minimize errors? Again, this should be outlined in your policy and closely followed by your staff. Do you have sample medications? How are these handled? Are they included in your policy? Samples are often treated as invisible items that aren’t really part of the facility stock, but in reality, this behavior can increase patient risks. A specific policy to deal with samples is also a good idea.

The end of the year is a great time to look back and reflect on the successes and failures. It’s a time to reflect on what went well and what we can do to improve in the days, weeks and months ahead. Take some time to consider these three items at your facility. Are you fully up to date on all three? If so, you’re in great shape…contact us and we will happily give you a longer list to work on. There is always room for improvement and the work is never fully done. When it comes to medication management and patient safety, the risk is never zero. We work hard all year long to minimize risks for our patients and facilities. Do the work now to start next year off on the right foot by making sure you have these three items taken care of!

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.