ED Accreditation Update: Medication issues trip up emergency departments

ED managers often find that compliance with the environment-of-care standards is one of the most challenging areas of accreditation, particularly when it comes to medication issues, say sources interviewed by ED Accreditation Update.

You must have a process for standardized drug calculations, sources say. Require use of standardized concentrations for high risk infusions, such as heparin, insulin, and vasopressors, suggests Monica Huber, RN, director of emergency, trauma, and intensive care services at Sioux Valley Hospital of the University of South Dakota Medical Center in Sioux Falls.

The latest example of standardization is insulin drips in 1 unit/ml concentration, and at her facility, there must be a written physician order to change the concentration, Huber says. A label is attached to the bag that says, "Contains insulin. Flush tubing with 50 ml of insulin solution prior to hanging first bag and with tubing changes."

Provide only one concentration for all medications administered via infusion when at all possible, she says. "If more than one concentration is necessary, i.e., heparin solution for arterial line flushes vs. dosing for [acute myocardial infarction] patients, utilize brightly colored warning labels and store in separate areas, such as the Pyxis."

Also, use pre-mixed solutions or always order infusions from pharmacy, she adds. "Do not allow infusions to be mixed by nursing staff on the patient care units," Huber says.

Any infusion requiring a calculation or high-risk infusion, including opiate drips, intravenous (IV) insulin, and patient-controlled analgesia programming, should require a double-check, she says. "This process includes the person doing the double-check starting the calculation from the beginning without knowing the answer the first person obtained," Huber adds.

Sioux Valley Hospital uses computerized calculations for weight-based infusions whenever possible. "There are programs available on the bedside monitors and on the [personal computers] in the department. Pharmacy also will print an infusion rate chart for individual patients if nursing provides them with patient weight and drug," she says.

For compliance with environment-of-care standards, check your medication drawers to ensure you don’t have any high-alert medications there, advises Eileen Whalen, MHA, RN, vice president of emergency, trauma, and perioperative services at University Medical Center in Tucson, AZ, and a consultant with AchieveMentors in Tolar, TX. Whalen spoke at the most recent leadership meeting of the Emergency Nurses Association.

At Huber’s facility, various warnings are programmed in the Pyxis that display when certain high-risk drugs are removed. "They are also programmed to prevent errors that have been identified as a trend in the medication error reporting system for our hospital or department," she says.

An auxiliary warning label is placed on all neuromuscular blocking agents, Huber says. The label says: "Danger. Muscle paralyzing agent. Patient must be intubated and mechanically ventilated with their use." Concentrated electrolytes, such as potassium and sodium, have been removed from Sioux Valley Hospital’s ED and must be ordered from pharmacy, she adds.

"Many hospitals have gone to the multiple-lock Pyxis-[type) system so that an extra door with the extra lock isn’t as necessary as it has been in past surveys," says Whalen, referring to systems such as the one manufactured by Pyxis Corp. in San Diego. Check with your pharmacy to determine if you have some leeway, she suggests.

Ensure you are complying with the Joint Commission’s requirement for using two forms of identification, Whalen emphasizes.

Many facilities use the medical record number and the name as the forms of identification, she says. Your staff and physicians need to understand the difference between the medical record number and the account number, Whalen emphasizes.

When you have an unidentified patient, use a permanent medical record number, she advises. Also, have a checkoff box on your flow sheet and in your nurses’ notes that indicates you checked the wristband and medical record number, she suggests.

To ensure compliance with Joint Commission standards, be familiar with the dangerous abbreviations, and deny any orders that include them, Whalen adds.

If a physician gives a verbal order, it must be said back, she says. "The say back’ is expected at all times, but the [Joint Commission] uses reasonableness such as during times of a full arrest or major trauma resuscitation," she says. "However, since significant errors can occur during the heat of the battle, one should attempt to adopt this habit as best practice even during acute emergencies."