Lessons from the New Jersey ASC sterilization incident — 11 deficiencies to watch

ASCs should take note of the deficiencies that led to an investigation of Saddle Brook, N.J.-based HealthPlus Surgery Center in late 2018, said Excellentia Advisory Group President and Managing Partner Cathy Montgomery, RN.

New Jersey posts survey results on its health department website, including a full statement of deficiencies and a submitted plan of correction, Ms. Montgomery said in an Excellentia Podcast episode. The statement of deficiencies for the ASC in question included 40 specific issues. It also showed an aggressive and well thought-out plan of correction, she said.

"I see at least one or two of these [infractions] on every survey that I do," she said. "But we fix them and move on."

She highlighted 11 deficiencies ASCs should pay special attention to:

Infection control:

1. Use of single-dose IV bags for multiple patients.
2. Unclear delegation of tasks, such as cleaning the anesthesia cart between cases
3. Outdated infection control policies

Pharmacy:

4. Lack of control over narcotics caused by improperly handling forms
5. Disparity between narcotics log and medical record entries
6. Confusion over narcotics waste stemming from unclear policies

Sterilization processes:

7. Not keeping the manufacturer's instructions for use
8. Having hinged instruments in the closed position
9. Finding rust on instruments
10. Putting too many instruments in a single pouch
11. Not maintaining the integrity of packages containing instruments (storing them flat, overstacked, crushed, bent, etc.)

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