Safe Medication Practices - California Ambulatory Surgery
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Transcript Safe Medication Practices - California Ambulatory Surgery
Stephanie McIntosh, RN BSN
Administrator
Rancho Bernardo Surgery Center
Agenda
•
Review JC/AAAHC/CMS regulations and
guidelines
•
Top Survey Citations
•
Infection Prevention
•
Encouraging Compliance
Goals
•
Understanding JC/AAAHC/CMS regulations
and guidelines
•
Awareness of Top Survey Citations
•
Knowledge of Infection Prevention Best
Practices
•
Tools for monitoring and promoting
Compliance
CMS Condition
for Coverage
416.48(a)
Administration of
Drugs
AAAHC
Chapter 11
Joint Commission
Medication
Management
Top 3 deficiencies
High-Alert
and
Hazardous
Medications
(MM
01.02.01)
(MM 03.01.01)
Look-alike /
Safely Stores Sound-alike
Medications Medications
(AAAHC 11.L)
(MM 01.01.03)
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
Raid the Fridge
Manufacturers
Guidelines
Anectine (succinylcholine chloride)
stored in the refrigerator (36-46F) but MDV are stable at
room temp for up to 14 days.
Rocuronium bromide
stored in the refrigerator (36-46F) but stable at room temp
for 60 days unopened and 30 days for open vials.
Refrigerated Medications
Light sensitive medications
Vaccinations
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
Lock it Up
Limiting access to prevent diversion
Control the keys
Cabinets
Carts
Drawers
Cupboards
Controlled
Substances,
Security and
Inspection
Track it Back
Controlled
Substances,
Security and
Inspection
Trace narcotics from receipt to administration,
destruction or return
C2 forms & Invoices
Narcotic log
Anesthesia sign out/records
Patient records
Lists can be life savers
Controlled
Substances,
Security and
Inspection
Know all the places that medications are kept
Don’t forget about your carts:
Anesthesia
Specialty
Malignant Hyperthermia
Crash carts
Create a schedule that rotates inspection areas
Collaborate with your consulting Pharmacist
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
I Spy
Expired,
Damaged and
Contaminated
Medications
Visually inspecting all medications before administering
Removes and stores separately until returned or destroyed
Services to return expired medication for a credit
Products to neutralize medications and dispose
Best Practice:
Consolidate medication storage areas
Backorders
Expired,
Damaged and
Contaminated
Medications
Have a plan-work with your Pharmacy consultant
Engage your purchaser and supply chain
Do you have current backorders list?
How are you alerting Teammates/Physicians/Anesthesia
Communicate backorders at team meeting and huddles
Post list on anesthesia carts
Email urgent backorders to MDs
Emergency medications with no substitute-keep the
medication but document the backorder and label it as expired
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
ASC Infection Control
Surveyor Worksheet
Handling and
Administration
II. Injection Practices (injectable medications, saline,
other infusates)
Observations are to be made of staff preparing and
administering medications and performing injections
(e.g., anesthesiologist, certified registered nurse
anesthetists, nurses).
Unless otherwise indicated, a “No” response to any question
below must be cited as a deficient practice in relation to 42
CFR 416.51 (a).
Hand Hygiene
Handling and
Administration
You can never have too much
Before donning gloves
After removing gloves
Mobile apps dedicated to
helping you monitor HH
Black light germ kits
Scrub the Hub
Handling and
Administration
Make sure you thoroughly “Scrub the hub” with
alcohol for 15 seconds before accessing vials and
administering IV medications
One and Only Campaign
Handling and
Administration
Needles and Syringes are used once-vials are
always entered with a new needle and syringe.
One and Only Campaign
Handling and
Administration
Exception-reconstituting medications or vaccines
• Use aseptic technique
• Designated clean medication area
Pediatric medications where
risk of overmedicating out
weighs risk of contamination
Reportable breaches
Handling and
Administration
Using the same needle for more than one individual
Using the same syringe, pen or injection device for more than
one individual
Re-using a needle or syringe used to administer medication to
an individual to enter a medication container (vial/bag/etc)
then administering contents to another individual
5/30/14 CMS Memo: Infection Control Breaches Which Warrant
Referral to Public Health Authorities Ref: S&C:14-36-All
Single Dose Vial (SDV)
Dedicated to Single patient
Accessed once
Must be used within one hour
Discarded immediately after use
Stored separately from MDV
Best Practice:
When in doubt-throw it out!
Handling and
Administration
Multi Dose Vial (MDV)
Handling and
Administration
Dedicated to single patient when possible
Can be accessed multiple times (new needle & syringe)
Dated with expiration date (28 days or IFU)
Discarded if in “immediate patient treatment area”
Best Practice:
When in doubt-throw it out!
“Immediate patient
treatment area”
Patient Rooms
Bays and
Bedsides
Handling and
Administration
Operating
Rooms
Medication Safety Rights
Handling and
Administration
1. Right Patient
2. Right Medication
3. Right Dose
4. Right Time
5. Right Route
26
Medication Safety Rights
Handling and
Administration
6. Right Indication
7. Right Documentation
8. Right Response
9. Right Education
10. Right to Refuse
27
Manufacturers
Guidelines
Labeling
Safe
Medication
Storage
Handling and
Administration
Controlled
Substances,
Security and
Inspection
Expired,
Damaged and
Contaminated
Medications
Labeling Medication
Syringes
Date
Time
Initials of person drawing
Medication name
Strength/concentration
Expiration Date
Discard date and time (up to one hour)
Labeling
Operating Rooms
Labeling
NPSG.03.04.01: Label all medications, medication containers,
and other solutions on and off the sterile field in perioperative
and other procedural settings.
Best Practice:
•Drawing up meds for immediate use
•Draw up before labeling
•Pre-printed labels (sterile for the back table)
• Don’t pour-use vial spike, filter straw or plastic catheters
Alphabetical is out!
Divide by Category
Utilize a color to designate categories
Separate Injectable, Oral and Topical medications
Labeling
Labeling
Look-alike/Sound-alike Medications
• Medications with names that are easily confused or
interchanged
High Risk/Alert Medications
• Medications involved with a high percentage of errors
or sentinel events as well are medications that are high
risk for abuse and other adverse outcomes
Hazardous Medications
• Studies indicate that exposures have potential for
causing cancer, developmental or reproductive toxicity
and or harm to organs
32
Look alike/Sound alike,
High Risk and
Hazardous Medications
List
Create
Implement
Educate
Labeling
Evaluate
Make The List
Labeling
Utilize your consulting pharmacist
Approved by Quality Council, Medical Executive
Board and Governing Board
Post it at the point of care as a resource
http://www.cdc.gov/niosh/docs/2012-150
http://www.ismp.org/Tools/confuseddrugnames.pdf
Labeling
Create and Implement
Limit concentrations of the same medication
Separate medications so they are not
stored next to each other
“Tall man” lettering
Signage
Stickers and Labels
Labeling
Educate and Evaluate
Labeling
Educate your teammates
Evaluate if the process is working
Process consistent throughout center
Make sure you can actually maintain it
Annual Review and revise (if necessary)
Cabinets and Carts
Labeling
38
Keeping up Compliance
Team creates the cultures, make sure to educate and
reinforce the importance
Checklists of drugs in each area
Rounds
Medication safety nurse
Make it fun
If your system needs an overhaul, make it a Performance
Improvement Project and take credit for all your hard work!
Spreadsheets are our Friends
Create rounds to highlight
medication focus areas
Medication Nurse or
delegate
Report to QC, MEC and GB
Calculating compliance for
PI Projects
Identify opportunities for
improvement and education
PI Project-Medication Administration
CURRENT SITUATION:
YTD we have had 3 medication errors, 2
of which involved a high risk medication
GOAL:
Reduce Medication errors to 0
ANAYLYSIS:
After reviewing the variances we have
identified:
1. Our process for labeling high risk meds
has not been fully implemented
2. Medications orders were not properly
stored
3. All rights of medication administration
were not being followed.
ACTION PLAN:
Review the rights of
medication administration
Look Alike/Sound Alike
medication storage will be
identified with yellow labels
with black lettering
High risk medication storage
areas will be labeled with red
lettering
High risk medication labels
will be available in all
medication preparation areas
High risk medications will be
transported in a specially
identified container
Responsible
Party
DON
DON
DON
DON
DON
Make it fun!
Questions?
43
Resources
http://www.cdc.gov/injectionsafety
http://www.apic.org/Resource_/TinyMceFileManager/Position_
Statements/AJIC_Safe_Injection0310.pdf
https://www.aaahc.org/Global/pdfs/AAAHC%20Institute%20co
ntent/aaahc_aeneid_report_FINAL.pdf
http://cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107_exhibit_3
51.pdf
http://www.ihi.org/resources/Pages/Tools/ScrubtheHubPosters
.aspx
http://www.ismp.org/Tools/confuseddrugnames.pdf
Resources
http://www.cdc.gov/niosh/docs/2012-150
http://www.oneandonlycampaign.org/
http://www.who.int/injection_safety/en/
http://www.jointcommission.org/standards_information/npsgs.
aspx
http://www.aorn.org/Secondary.aspx?id=26250&terms=medic
ation