Common deficiencies cited by AAAASF and how to fix them: Administration of drugs

In our ongoing series, Becker's ASC Review spoke with American Association for Accreditation of Ambulatory Surgery Facilities’ Director of Accreditation Jeanne Henry about the organization's commonly cited deficiency related to administration of drugs.

Jeanne Henry: CMS standard 416.48(a) requires ASCs to prepare and administer drugs according to established policies and acceptable standards of practice. AAAASF surveyors site cite this standard deficient for a number of reasons, including finding expired medications, inappropriate storage, improper use of a medication or inappropriate preparation techniques. The process for medication preparation and administration can be error-prone. To improve medication safety, ASCs should assess their medication process using quality indicators related to the medication preparation and administration processes and outcomes of patient care.

We find that proper medication preparation is a key component to compliance with this standard. Adopting strict policies and providing ongoing personnel training help to safeguard the preparation processes. Preparing medications in an aseptic manner, using a new syringe and new sterile needle to draw up medications each and every time should be required.

Simple safety measures such as conducting correct hand hygiene prior to handling medications and disinfecting the rubber septum’s on medication vials help to guarantee desirable patient care outcomes. Common practices should include discarding medication vials whenever the sterility is in question and dedicating multidose vials to a single patient whenever possible.

Additionally, expiration dates of all medication preparation and delivery accessories should be verified before use. The expiration of on-site sterilized equipment is event-based — if there's any doubt regarding the integrity of the packaging, the equipment should not be used. Events which can compromise the effectiveness of the packaged, sterile material include tears in packaging, moisture and the packaged item being dropped on a contaminated surface such as the floor, whereas any sterile equipment processed off-site has an expiration date that should be adhered to, unless an event contaminates the item prior to the expiration date.

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