Accrediting bodies, safety organizations and other overseers of the healthcare industry are clearly focused on safe management of medications as underscored by recent surveys, media attention and aggressive advertising by legal firms to the public. In our practice, virtually every week, ASCs we work with are surveyed, and we continue to see the same theme: Safe medication management and performance assessment is front and center.
Accrediting bodies, safety organizations and other overseers of the healthcare industry are clearly focused on safe management of medications as underscored by recent surveys, media attention and aggressive advertising by legal firms to the public. In our practice, virtually every week, ASCs we work with are surveyed, and we continue to see the same theme: Safe medication management and performance assessment is front and center.
We believe that good outcomes have a lot to do with good medication management, and that good outcomes generate good incomes. And if you believe, like we do, that poor survey outcomes are distracting, time-consuming and costly (some payors are holding back reimbursement when avoidable medication errors occur), and that medication errors that are predictable and preventable represent a high cost in patient care quality, litigation and poor reputation; then best practice and safe medication strategies are, in reality, cost-containment ideas as well.
Perhaps most visible and vulnerable (on survey) as well as presenting attractive opportunities for the facility’s stakeholders is medication management in the area of anesthesiology. Presented below are 10 ideas that have worked for us.
1. Labeling. Poor syringe labeling is unsafe, National Patient Safety Goal-noncompliant, and only invites litigation against your ASC. Syringes that fail the safety test: those that are pre-drawn and don’t contain the name and strength of the medication. To avoid the errors this poses, we suggest mandating that all syringes be labeled with name and strength, and enacting a firm policy that unused syringes are never saved for the next day’s procedures. Pre-printed labels are commonly available with names and strengths to aid compliance.
2. Become a formulary activist. Every facility should have a formulary that is embraced by its medical executive committee; at least annually, additions and deletions to the formulary should be made. The anesthesiologist is in a key position to chaperone formulary management, and so should continually review for drugs that have fallen into disuse or are duplicative, or, alternatively, that have earned consideration for admission to the formulary. Further, initiatives such as minimization or elimination of multiple-dose vials should routinely appear on the medication safety agenda.
3. Multiple-dose vials. Multiple-dose vials are a hotbed of controversy when poorly managed, but their use is neither wrong nor illegal. However, most overseers agree that their use should be minimized and, where alternatives exist, that they be considered.
Some single-dose vials look like multiple-dose vials (i.e., esmolol), but do not contain preservatives or antimicrobials, so such use is clearly unsafe. We suggest a 28-day rule for facility-imposed outdating on multiple-dose vials. For consistency, don’t label the open date, rather, enter a month (minus two days) with the date and “Exp__” notation.
4. Prepare for malignant hyperthermia via in-service. The frequency is small, but the occurrence is insidious and unpredictable (see “Four Steps to Prepare for Malignant Hyperthermia” on p. 33). For facilities that use trigger anesthetics and paralytics, champion an educational program for anesthesia and nursing staffs by your team, the consultant pharmacist or both at least annually. No personnel should be faced with handling dantrolene for the first time should an event occur. Don’t let outdated dantrolene (it has a shelf life of two years) go to waste: Use it to practice mixing. And that brings us to No. 5.
5. Dote on antidotes. Safety guidelines lay out the expected armamentarium each facility should have on hand — and, equally importantly, that staff should be educated on — in addition to dantrolene. Drugs such as neostigmine, methylene blue (methemoglobinemia), Intralipid (bupivicaine-induced
cardiotoxicity), naloxone and flumazenil should be considered as standard formulary additions depending on your facility’s specialties.
6. Manage pharmaceutical waste. The Resource Conservation and Recovery Act (RCRA), which was assigned to the Environmental Protection Agency for enforcement, covers the responsibility of pharmaceutical waste generators with regard to how discarded pharmaceuticals are to be managed. There have been numerous articles that reveal the environmental risks and regulatory expectations. Familiarize yourself with this issue, which looms large in media and legal attention, and in potentially significant fines for noncompliance.
7. The medical record and your part in it. We are seeing more and more that medical records that are illegible, have vague or inexplicit orders, use “dangerous abbreviations” and fail to tally anesthetics administered are not passing muster. In addition, the anesthesiologist is perfectly positioned to help develop standard orders sets, particularly in the PACU, that are explicit and dose limiting. Misinterpretation errors are virtually eliminated here when you have a multidisciplinary team developing these sets.
8. Histories and physicals and your part in them. The repercussions of failing to meet CMS survey standards are significant in their impact on your facility, especially financially. H&Ps that are not current, as well as failure to note pain assessment on admission and discharge, have been a focus on recent CMS surveys, so be sure these elements are in place.
9. Benchmark your costs. Knowing your costs for common high-cost and/or high-volume drugs is a must in today’s fiscal environment. You should be working with your pharmacy consultant to
understand to the best of your ability the costs your facility is incurring for anesthetic drugs. We have
witnessed remarkable rollbacks in costs for facilities that are armed with relative cost information.
10. Back up your temperature control. Refrigerators should be powered by generator-served outlets. Facilities sometimes stock thousands of dollars worth of drugs in their medication refrigerators — a power outage that is not reasonably quickly repaired would beckon the question of the stability of drugs stored within. The right answer, in such cases, is usually to discard what you have. The better answer is to prevent it in the first place by ensuring that the refrigerator(s) housing drugs is on a generator-supplied wall outlet.
Mr. Sones (shelsones@aol.com) is a safe medication management and pharmacy consultant and is president of Sheldon S. Sones and Associates of Newington, Conn., currently serving over 100 ASCs in the Northeast (www.sheldonsones.com).
Medication Safety Index
The following monitoring criteria are drawn from standards established by accrediting agencies as well as best practice experience, and embracing the work of the Institute for Safe Medication Practices and the National Quality Forum. We monitor all our facilities for their current medication safety index based on their compliance; as such, they have been discussed thoroughly. I suggest you follow up and seek thorough explanations for each of the following 16 criteria before implementing them as a guide in your facility.
1. All patients identified by wristband.
2. Allergies conspicuously noted and followed through on the chart.
3. Interviewed nurses answer correctly regarding oral orders read back after writing; this is known as verbal orders repeated back, or VORB.
4. No evidence of co-mingling of drugs in common sections of med carts or cabinets.
5. Med (or IV) orders are not vague; for example, “Fentanyl 50 mcg prn for pain” lacks frequency allowed and ceiling dose, KVO.
6. Dangerous abbreviations are posted and, using tracer methodology, are not evident in the medical record and/or on labels.
7. Evidence that the code cart is checked monthly by different staff members to maintain familiarity with contents; good cart status.
8. Evidence of effective process for tracking drug recalls (i.e., the recall folder is not empty).
9. Interviewed nurses answer correctly regarding two-method requirement for patient identification.
10. Medications are labeled accurately and fully and in-date. All meds signed for.
11. Empty syringes are not pre-labeled.
12. Maintain a list of look-alike, sound-alike and high-alert drugs, and the policy for their management.
13. Develop or have developed a satisfactory methodology to communicate drugs administered post-operatively or new prescription upon discharge to the next provider of care. This is known as reconciliation.
14. Maintaining more than one strength of drugs if not clearly necessary: lidocaines, for example, are OK, while many strengths of morphine is not a good idea.
15. The medical records are substantially legible in all cases.
16. Infusion pumps available for those drugs requiring controlled administration, such as dopamine.
— Sheldon S. Sones, RPh, FASCP
We believe that good outcomes have a lot to do with good medication management, and that good outcomes generate good incomes. And if you believe, like we do, that poor survey outcomes are distracting, time-consuming and costly (some payors are holding back reimbursement when avoidable medication errors occur), and that medication errors that are predictable and preventable represent a high cost in patient care quality, litigation and poor reputation; then best practice and safe medication strategies are, in reality, cost-containment ideas as well.
Perhaps most visible and vulnerable (on survey) as well as presenting attractive opportunities for the facility’s stakeholders is medication management in the area of anesthesiology. Presented below are 10 ideas that have worked for us.
1. Labeling. Poor syringe labeling is unsafe, National Patient Safety Goal-noncompliant, and only invites litigation against your ASC. Syringes that fail the safety test: those that are pre-drawn and don’t contain the name and strength of the medication. To avoid the errors this poses, we suggest mandating that all syringes be labeled with name and strength, and enacting a firm policy that unused syringes are never saved for the next day’s procedures. Pre-printed labels are commonly available with names and strengths to aid compliance.
2. Become a formulary activist. Every facility should have a formulary that is embraced by its medical executive committee; at least annually, additions and deletions to the formulary should be made. The anesthesiologist is in a key position to chaperone formulary management, and so should continually review for drugs that have fallen into disuse or are duplicative, or, alternatively, that have earned consideration for admission to the formulary. Further, initiatives such as minimization or elimination of multiple-dose vials should routinely appear on the medication safety agenda.
3. Multiple-dose vials. Multiple-dose vials are a hotbed of controversy when poorly managed, but their use is neither wrong nor illegal. However, most overseers agree that their use should be minimized and, where alternatives exist, that they be considered.
Some single-dose vials look like multiple-dose vials (i.e., esmolol), but do not contain preservatives or antimicrobials, so such use is clearly unsafe. We suggest a 28-day rule for facility-imposed outdating on multiple-dose vials. For consistency, don’t label the open date, rather, enter a month (minus two days) with the date and “Exp__” notation.
4. Prepare for malignant hyperthermia via in-service. The frequency is small, but the occurrence is insidious and unpredictable (see “Four Steps to Prepare for Malignant Hyperthermia” on p. 33). For facilities that use trigger anesthetics and paralytics, champion an educational program for anesthesia and nursing staffs by your team, the consultant pharmacist or both at least annually. No personnel should be faced with handling dantrolene for the first time should an event occur. Don’t let outdated dantrolene (it has a shelf life of two years) go to waste: Use it to practice mixing. And that brings us to No. 5.
5. Dote on antidotes. Safety guidelines lay out the expected armamentarium each facility should have on hand — and, equally importantly, that staff should be educated on — in addition to dantrolene. Drugs such as neostigmine, methylene blue (methemoglobinemia), Intralipid (bupivicaine-induced
cardiotoxicity), naloxone and flumazenil should be considered as standard formulary additions depending on your facility’s specialties.
6. Manage pharmaceutical waste. The Resource Conservation and Recovery Act (RCRA), which was assigned to the Environmental Protection Agency for enforcement, covers the responsibility of pharmaceutical waste generators with regard to how discarded pharmaceuticals are to be managed. There have been numerous articles that reveal the environmental risks and regulatory expectations. Familiarize yourself with this issue, which looms large in media and legal attention, and in potentially significant fines for noncompliance.
7. The medical record and your part in it. We are seeing more and more that medical records that are illegible, have vague or inexplicit orders, use “dangerous abbreviations” and fail to tally anesthetics administered are not passing muster. In addition, the anesthesiologist is perfectly positioned to help develop standard orders sets, particularly in the PACU, that are explicit and dose limiting. Misinterpretation errors are virtually eliminated here when you have a multidisciplinary team developing these sets.
8. Histories and physicals and your part in them. The repercussions of failing to meet CMS survey standards are significant in their impact on your facility, especially financially. H&Ps that are not current, as well as failure to note pain assessment on admission and discharge, have been a focus on recent CMS surveys, so be sure these elements are in place.
9. Benchmark your costs. Knowing your costs for common high-cost and/or high-volume drugs is a must in today’s fiscal environment. You should be working with your pharmacy consultant to
understand to the best of your ability the costs your facility is incurring for anesthetic drugs. We have
witnessed remarkable rollbacks in costs for facilities that are armed with relative cost information.
10. Back up your temperature control. Refrigerators should be powered by generator-served outlets. Facilities sometimes stock thousands of dollars worth of drugs in their medication refrigerators — a power outage that is not reasonably quickly repaired would beckon the question of the stability of drugs stored within. The right answer, in such cases, is usually to discard what you have. The better answer is to prevent it in the first place by ensuring that the refrigerator(s) housing drugs is on a generator-supplied wall outlet.
Mr. Sones (shelsones@aol.com) is a safe medication management and pharmacy consultant and is president of Sheldon S. Sones and Associates of Newington, Conn., currently serving over 100 ASCs in the Northeast (www.sheldonsones.com).
Medication Safety Index
The following monitoring criteria are drawn from standards established by accrediting agencies as well as best practice experience, and embracing the work of the Institute for Safe Medication Practices and the National Quality Forum. We monitor all our facilities for their current medication safety index based on their compliance; as such, they have been discussed thoroughly. I suggest you follow up and seek thorough explanations for each of the following 16 criteria before implementing them as a guide in your facility.
1. All patients identified by wristband.
2. Allergies conspicuously noted and followed through on the chart.
3. Interviewed nurses answer correctly regarding oral orders read back after writing; this is known as verbal orders repeated back, or VORB.
4. No evidence of co-mingling of drugs in common sections of med carts or cabinets.
5. Med (or IV) orders are not vague; for example, “Fentanyl 50 mcg prn for pain” lacks frequency allowed and ceiling dose, KVO.
6. Dangerous abbreviations are posted and, using tracer methodology, are not evident in the medical record and/or on labels.
7. Evidence that the code cart is checked monthly by different staff members to maintain familiarity with contents; good cart status.
8. Evidence of effective process for tracking drug recalls (i.e., the recall folder is not empty).
9. Interviewed nurses answer correctly regarding two-method requirement for patient identification.
10. Medications are labeled accurately and fully and in-date. All meds signed for.
11. Empty syringes are not pre-labeled.
12. Maintain a list of look-alike, sound-alike and high-alert drugs, and the policy for their management.
13. Develop or have developed a satisfactory methodology to communicate drugs administered post-operatively or new prescription upon discharge to the next provider of care. This is known as reconciliation.
14. Maintaining more than one strength of drugs if not clearly necessary: lidocaines, for example, are OK, while many strengths of morphine is not a good idea.
15. The medical records are substantially legible in all cases.
16. Infusion pumps available for those drugs requiring controlled administration, such as dopamine.
— Sheldon S. Sones, RPh, FASCP