Bernard McDonnell, DO, a retired physician and current surveyor for Healthcare Facilities Accreditation Program, previously identified "20 Questions Surgery Centers Should Ask to Ensure an Acceptable and Effective Infection Prevention Program." Here he identifies 20 questions ASCs need to ask themselves to help ensure they have a safe and effective medication management program.
1. Can your ASC say it is providing patients with drugs and biologicals in a safe and effective manner? Dr. McDonnell quotes directly from the Conditions of Participation for ASCs: "ASCs must provide drugs and biologicals in a safe and effective manner in accordance with accepted professional practice under the direction of an individual responsible for pharmaceutical services."
He says, "In other words, if you're going to use drugs in your ASC, you better do it right and you better have accepted standards of practice."
2. Do you have someone responsible for your pharmaceutical services? Who is responsible for your drugs? If it is not a pharmacist, which would be the best, who is it? Who is in charge? What is his or her responsibility to the facility and to the patient?
"There has to be a person designated in this rule and this person should be a licensed healthcare professional," Dr. McDonnell says. Check your state laws and find out if this person must be a licensed pharmacist.
"The takeaway is you have to have a licensed professional in charge of this and that person will be the safety person to direct the program and provide oversight," he says.
3. Do you have the necessary policies in place for the program? Do you have policies that spell out how you are going to administer the program? Do you have policies for injectables? Do you have policies for PO drugs? If you are doing general anesthesia, what are your policies for those drugs, such as inhalation agents like sevoflurane?
4. Who is designated to administer the drugs? Do you have a nurse administering them or is it somebody else? "In the ASC, the drugs should be administered by a nurse," Dr. McDonnell says.
5. What are your policies when you have drugs in the sterile field? Who's labeling the drug? Who's responsible for drawing it up? "When you put the drugs in the sterile field in syringes, they must be labeled — both on and off the field," Dr. McDonnell says. "Everything looks like water; it's all clear. Make sure everything is labeled and labeled properly."
6. Do you have someone responsible for separating or differentiating look-alike/sound-alike drugs?
7. Are you monitoring adverse drug reactions and medication errors? "These are the kinds of things that need to be looked at, ADRs especially," Dr. McDonnell says.
8. Do you have a process for adjusting the medication on a patient by patient basis? Are you overdosing, giving too much pain medication to patients? "You have a cookbook of pre-op meds you use," he says. "Are you adjusting the doses, taking into consideration the patient's weight? Adjusting the medication isn't just for pediatrics. Do not be complacent with the cookbook of what you're to give pre-op."
9. Do you have policies and practices in place to prevent diversion of drugs? Are you monitoring the drugs, making sure they are always locked up? "Anybody can divert," says Dr. McDonnell. "Everyone from the surgeon to the person cleaning the room is a potential for non-secure drugs. You have to realize that."
10. Are you not allowing drugs to be pre-drawn several cases in advance? "Drugs that are drawn up and lined up, maybe 3-4 cases down the road, is unacceptable," he says. "If the 8:00 patient has his drugs, you don't have the 10:00 patient's drugs and 11:00 patient's drugs all drawn up and lined up, non-secure. That's just an invitation to disaster, not only for diversion but for making mistakes."
11. If you have a Pyxis machine, are you actually using it? "It's wonderful to have this machine but not if all of the [drugs] are just lying on top of it rather than inside it," Dr. McDonnell says.
12. Do you have policies for antibiotics? While the Surgical Care Improvement Project (SCIP) measures are for inpatient facilities, it's still critical that ASCs monitor the antibiotics for their patients. Dr. McDonnell says, "ASCs need to ask, 'Are we giving antibiotics appropriately pre-op and post-op? Do we know what to ask and why we're asking concerning our patients' antibiotics?"
13. Do you consider whether patients are on Beta Blockers. "Are you looking at patients on Beta Blockers," Dr. McDonnell says. "Do you at least know [if patients are on Beta Blockers] and do you either continue them or have a reason you shouldn't continue them at the time of surgery? You have to evaluate it and make an educated decision. That really is up to the anesthesiologist or physician."
14. Does your history and physical form capture what drugs the patient is taking? Do you know what drugs your patients are on? Do you do medication reconciliation when patients come to your ASC? Do you capture a list of the medications the patient is taking at home?
15. Do you send the patients home with medication instructions? Do you tell them what new medications to take, if any, or how to change medications they were taking as a result of their procedure and any new medications they are on or will be taking? Are you doing medication reconciliation ("med rec")?
16. When you give new medications to a patient, do you consider what medications the patient is currently on or taking? "What if the patient is on Coumadin or aspirin?" Dr. McDonnell says. "That's something that is extraordinarily important to know, what is the person coming on in? You do need to know what the patient is on … including any herbals. Make sure you understand what the patient is on and understand the [medications'] ramifications."
17. If you do general anesthesia, are you prepared for malignant hyperthermia? Do you have a malignant hyperthermia cart? Do you have adequate supplies of dantrolene that is not out of date? Do you educate staff on the use of dantrolene? "This drug is very difficult to mix up," Dr. McDonnell says. "It's an event. If you have a patient with malignant hyperthermia, time is of the essence. Malignant hyperthermia, while rare, is catastrophic.
"An idea for training would be if your dantrolene is out of date and you can't get any kind of rebate from the manufacturer on the drug, set up the out-of-date dantrolene and use it for a drill, training your staff with it," he says.
18. Do you have to have a transfer agreement in place? An ASC is required to have either a transfer agreement in place or every surgeon in the ASC to be on the staff of the local hospital, Dr. McDonnell says. "I would much rather see a transfer agreement," he says. "In the event of malignant hyperthermia, or more commonly a post-op respiratory problem or a post-op flash pulmonary edema you can't take care of, the first thing you do is call 911, the second thing they do is call and start that transfer agreement."
19. Do you have a drug education program for your staff and physicians? It would likely be the job of anesthesia and nursing to ensure your staff members understand the different types of drugs that are available and used by the ASC. "It doesn't have to be a college course; maybe do a regular 7-7:30 presentation on the drugs and their actions," Dr. McDonnell says. "Make sure the staff understand [what they are taught] and document such in their files.
"Physicians should have education as well," he says. "I would put this on the anesthesiologist who could do a newsletter or something online the physicians can access."
20. Do you always follow and enforce your policies and procedures? "It's easy to get very complacent" and deviate from the rules, Dr. McDonnell says. "That's one of the biggest problems I've seen in ASCs and hospitals doing a lot of outpatient surgery; it's routine stuff, day after day, and that's when you need to be careful of complacency."
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