Accreditation Challenge: Failure to Label Pre-Drawn Medications Properly

Written by Rob Kurtz | July 22, 2010

Social Sharing  

Jack Egnatinsky, MD, medical director of the AAAHC and a retired anesthesiologist, discusses the common ASC accreditation challenge of failing to properly label pre-drawn medications and what organizations should do to avoid making this mistake.

Dr. Jack Egnatinsky: AAAHC's 2010 standards require ASCs to have an infection control plan in place. As part of that plan, they must demonstrate their plan is consistent with "CDC or other nationally recognized guidelines for safe injection practices." In addition, if the ASC is Medicare-certified, the Medicare Infection Control Worksheet for Surveyors, which should be completed on all deemed status surveys (available on line for organizations to download by clicking here (pdf)) requires, in Part II-Section II.E: "Medications that are pre-drawn are labeled with the time of draw, initials of the person drawing, medication name, strength and expiration date or time."

It is rare that we find all of this required information on labels of syringes with medications pre-drawn that will not be immediately administered. Most often missing are the strength of the medication and the time the medication was drawn up or the expiration time (based on the organizations policies). Next most frequent is the failure to initial the label. Many of the commercially available adhesive labels on rolls do not have room for all of this information, so the organization may have to look for different labels, make up their own or write all the information on a piece of adhesive tape for use as a label.

Learn more about AAAHC.

Read more insight on meeting AAAHC standards:

- Guidance for Preventing Patient Falls

- Guidance for Proper Peer Review

- Radiologist Required to Supervise ASC Radiological Services