SDS Accreditation Update

Medication safety tops list of surveyors' focus

Reconciliation, labeling, prescribing, and tracking required

Patient safety goals and all standards related to patient safety top the list of items focused upon by The Joint Commission surveyors, according to outpatient managers surveyed during recent months.

Medication safety is a key focus, says Lynn Burgett, RN, BSN, administrator of Lakeshore Surgery Center in Fort Gratiot, MI. One area that has presented a challenge for Burgett's center is the National Patient Safety Goal requiring reconciliation of medications at admission and upon discharge, she admits. "We have struggled with different ways to comply with this goal's requirements but had not successfully addressed it at the time of our survey," she says.

During the survey, Burgett and her staff presented the surveyor with several ideas that they were considering, and the surveyor offered suggestions, she says. "We now have a one-sheet carbon copy form that collects all of the medication information that we need prior to surgery and at discharge," she says. Information includes the name, dose, and frequency of medications, as well as instructions for the patient regarding stopping and restarting specific medications, she explains. One copy of the form is given to the patient at discharge so the patient has a complete list of medications, including any medications prescribed on the day of surgery, she adds. Experts also recommend that a copy of the medication form be sent to the surgeon so that he or she is aware of medications given by the anesthesiologist after the surgeon has left the surgery area. This helps the surgeon in case of complications that require admission or telephone consultation with the patient the night of surgery or the next day.

Labeling medications that are drawn into a syringe for use in a procedure was a focus of the surveyor at North Texas Surgery Center in Dallas, says Melody Heatherley, PhD, RN, CNOR, CASC, director of nursing. "The surveyor checked all medication in the pre-op, PACU, and the OR to make sure that they were clearly labeled with the name of the medication as well as the date drawn," she says. Other Joint Commission requirements for the label include quantity and dosage, she adds.

Although Heatherley's nursing staff members are aware of the need to label all medications, the toughest part of ensuring compliance with this requirement is with the anesthesiologists, she says. "Our anesthesiologists will draw medication for an eye block to be performed in the pre-op area, then place the syringe in their pockets as they walk to the patients," she says. Because they have just drawn the medication and are heading straight to the patient, they often don't take time to label the syringe, she admits. "Changing this behavior will take time and continuous education," she says.

In addition to reminders at medical staff meetings, Heatherley will routinely ask an anesthesiologist if the syringe in his or her pocket is labeled. "The one-on-one monitoring is important, because I remind them that this is not a rule I implemented, it is a requirement for our accreditation," she says. "I also focus on medication labeling in all of our mock surveys that involve all staff members, including physicians."

Even if the physician is not walking from one location to another, labeling is required, points out Burgett. "The nursing staff labels everything in the OR, but our surveyor observed one of our anesthesiologists performing a pain management procedure," she says. The physician had a circulator in the room, but no other nursing staff. "He drew the medication for the procedure with the patient in the room, then immediately started the procedure," Burgett says. The surveyor pointed out that labeling the syringe still was necessary, she adds.

Sample meds must be tracked

The emphasis on medication safety extends to sample medications and prescriptions, points out Marion Benson, vice president and executive director of Good Shepherd Ambulatory Surgical Center in Longview, TX. "The surveyor asked if we had sample medications or if we dispensed medications," she says. The policies that related to documentation of inventory, expiration dates, and order writing for these medications were reviewed, Benson says.

"We were surprised to find out that the complimentary eye bags that our ophthalmologists asked us to give their patients were considered medications," says Burgett. The bags, which are given to the physicians by pharmaceutical companies, contain items that a cataract patient needs following surgery such as eyedrops, patch, and eye shield, she explains. "The bags also have a pocket on the outside that we use to hold the card that contains information on the implant the patient received," Burgett adds.

Because the bags contain prescription eyedrops, the surveyor pointed out that they are considered medications and that the surgery center staff must log every bag received, verify and document expiration dates, and track distribution of each bag, she recalls. "Even if the drops are over-the-counter medications, it is still necessary for a staff person to check expiration dates and track distribution," Burgett points out. "We were distributing the bags as a convenience for both the patient and physician, but we've changed our practice since the survey," she says. Now, the eye bags are given to the patient in the physician's office prior to surgery, and her staff reminds the patient to use the eye drops at discharge, she adds.

Copy controlled substance prescriptions

Another tip from Burgett's surveyor is extra protection for the surgery program as well as the physician. "He recommended that we make a photocopy of every prescription for controlled substances that we give to patients and include that copy in the chart," she says. "Because prescriptions for controlled substances have been altered to obtain additional refills or increased number of pills, the copy in the chart proves the dose, frequency, and number of refills ordered by the physician."

In addition to medication safety practices, Heatherley's surveyor also asked about physicians' awareness of their responsibilities in case of a surgical fire. "He wanted to know that if he stopped a surgeon and asked him about his role in a patient fire, the surgeon could answer accurately," she says. The surveyor pointed out that the physician should say: "Remove any burning materials from the patient and help put the fire out by putting the materials on the floor and extinguishing the fire, control any bleeding and prepare patient in case evacuation is necessary, put sterile towels over the surgical site if we need to move the patient, otherwise, finish surgery as quickly as possible and help move the patient." There is no confusion in her center, and physicians do know their responsibilities, she says. "We have a chart posted in the OR that describes everyone's role," she adds. [See a copy of the fire responsibility chart.]

Physicians must be involved in all patient safety activities, Heatherley says. "Our surveyor wanted to see minutes of the medical executive committee and other medical committee meetings at which we presented quality improvement [QI] studies related to patient safety," she says. This was no problem for Heatherley, because physicians on these committees often will suggest QI studies and participate in the studies, she says.

Reporting trends and ideas for QI studies is not enough, says Heatherley. "Our surveyor wanted to see closure," she says. "He wanted to see how we report the study findings and actions taken to improve performance back to medical staff members."