1. Stephanie McIntosh, RN BSN Administrator Rancho Bernardo Surgery Center

2. Agenda Review JC/AAAHC/CMS regulations and guidelines Top Survey Citations Infection Prevention Encouraging Compliance

3. Goals Understanding JC/AAAHC/CMS regulations and guidelines Awareness of Top Survey Citations Knowledge of Infection Prevention Best Practices Tools for monitoring and promoting Compliance

4. CMS Condition for Coverage 416.48(a) Administration of Drugs AAAHC Chapter 11 Joint Commission Medication Management

5. Top 3 deficiencies Safely Stores Medications (MM 03.01.01) Look-alike / Sound-alike Medications (MM 01.02.01) (AAAHC 11.L) High-Alert and Hazardous Medications (MM 01.01.03)

6. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

7. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

8. Raid the Fridge Anectine (succinylcholine chloride) stored in the refrigerator (36  -46  F) but MDV are stable at room temp for up to 14 days. Rocuronium bromide stored in the refrigerator (36  -46  F) but stable at room temp for 60 days unopened and 30 days for open vials. Refrigerated Medications Light sensitive medications Vaccinations Manufacturers Guidelines

9. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

10. Lock it Up Limiting access to prevent diversion Control the keys Cabinets Carts Drawers Cupboards Controlled Substances, Security and Inspection

11. Track it Back Trace narcotics from receipt to administration, destruction or return C2 forms & Invoices Narcotic log Anesthesia sign out/records Patient records Controlled Substances, Security and Inspection

12. Lists can be life savers Know all the places that medications are kept Don’t forget about your carts: Anesthesia Specialty Malignant Hyperthermia Crash carts Create a schedule that rotates inspection areas Collaborate with your consulting Pharmacist Controlled Substances, Security and Inspection

13. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

14. I Spy Visually inspecting all medications before administering Removes and stores separately until returned or destroyed Services to return expired medication for a credit Products to neutralize medications and dispose Expired, Damaged and Contaminated Medications Best Practice: Consolidate medication storage areas

15. Backorders Have a plan-work with your Pharmacy consultant Engage your purchaser and supply chain Do you have current backorders list? How are you alerting Teammates/Physicians/Anesthesia Communicate backorders at team meeting and huddles Post list on anesthesia carts Email urgent backorders to MDs Expired, Damaged and Contaminated Medications Emergency medications with no substitute-keep the medication but document the backorder and label it as expired

16. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

17. ASC Infection Control Surveyor Worksheet II. Injection Practices (injectable medications, saline, other infusates) Observations are to be made of staff preparing and administering medications and performing injections (e.g., anesthesiologist, certified registered nurse anesthetists, nurses). Handling and Administration Unless otherwise indicated, a “No” response to any question below must be cited as a deficient practice in relation to 42 CFR 416.51 (a).

18. Hand Hygiene You can never have too much Before donning gloves After removing gloves Mobile apps dedicated to helping you monitor HH Black light germ kits Handling and Administration

19. Scrub the Hub Make sure you thoroughly “Scrub the hub” with alcohol for 15 seconds before accessing vials and administering IV medications Handling and Administration

20. One and Only Campaign Needles and Syringes are used once-vials are always entered with a new needle and syringe. Handling and Administration

21. One and Only Campaign Exception-reconstituting medications or vaccines Use aseptic technique Designated clean medication area Handling and Administration Pediatric medications where risk of overmedicating out weighs risk of contamination

22. Reportable breaches Using the same needle for more than one individual Using the same syringe, pen or injection device for more than one individual Re-using a needle or syringe used to administer medication to an individual to enter a medication container (vial/bag/etc) then administering contents to another individual 5/30/14 CMS Memo: Infection Control Breaches Which Warrant Referral to Public Health Authorities Ref: S&C:14-36-All Handling and Administration

23. Single Dose Vial (SDV) Dedicated to Single patient Accessed once Must be used within one hour Discarded immediately after use Stored separately from MDV Handling and Administration Best Practice: When in doubt-throw it out!

24. Multi Dose Vial (MDV) Dedicated to single patient when possible Can be accessed multiple times (new needle & syringe) Dated with expiration date (28 days or IFU) Discarded if in “immediate patient treatment area” Handling and Administration Best Practice: When in doubt-throw it out!

25. “Immediate patient treatment area” Patient RoomsBays and Bedsides Operating Rooms Handling and Administration

26. Medication Safety Rights 26 1. Right Patient2. Right Medication 3. Right Dose 4. Right Time5. Right Route Handling and Administration

27. Medication Safety Rights 27 6. Right Indication7. Right Documentation8. Right Response9. Right Education10. Right to Refuse Handling and Administration

28. Safe Medication Storage Manufacturers Guidelines Controlled Substances, Security and Inspection Expired, Damaged and Contaminated Medications Handling and Administration Labeling

29. Labeling Medication Syringes DateTimeInitials of person drawingMedication nameStrength/concentrationExpiration DateDiscard date and time (up to one hour) Labeling

30. Operating Rooms NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Labeling Best Practice: Drawing up meds for immediate use Draw up before labeling Pre-printed labels (sterile for the back table) Don’t pour-use vial spike, filter straw or plastic catheters

31. Alphabetical is out! Divide by Category Utilize a color to designate categories Separate Injectable, Oral and Topical medications Labeling

32. 32 Medications with names that are easily confused or interchanged Look-alike/Sound-alike Medications Medications involved with a high percentage of errors or sentinel events as well are medications that are high risk for abuse and other adverse outcomes High Risk/Alert Medications Studies indicate that exposures have potential for causing cancer, developmental or reproductive toxicity and or harm to organs Hazardous Medications Labeling

33. ListCreateImplementEducateEvaluate Look alike/Sound alike, High Risk and Hazardous Medications Labeling

34. Make The List Utilize your consulting pharmacist Approved by Quality Council, Medical Executive Board and Governing Board Post it at the point of care as a resource Labeling http://www.cdc.gov/niosh/docs/2012-150 http://www.ismp.org/Tools/confuseddrugnames.pdf

35. Labeling

36. Create and Implement Limit concentrations of the same medication Separate medications so they are not stored next to each other “Tall man” letteringSignageStickers and Labels Labeling

37. Educate and Evaluate Educate your teammatesEvaluate if the process is workingProcess consistent throughout centerMake sure you can actually maintain itAnnual Review and revise (if necessary) Labeling

38. Cabinets and Carts 38 Labeling

39. Keeping up Compliance Team creates the cultures, make sure to educate and reinforce the importance Checklists of drugs in each area Rounds Medication safety nurse Make it fun If your system needs an overhaul, make it a Performance Improvement Project and take credit for all your hard work!

40. Spreadsheets are our Friends Create rounds to highlight medication focus areas Medication Nurse or delegate Report to QC, MEC and GB Calculating compliance for PI Projects Identify opportunities for improvement and education

41. PI Project-Medication Administration CURRENT SITUATION: YTD we have had 3 medication errors, 2 of which involved a high risk medication GOAL: Reduce Medication errors to 0 ANAYLYSIS: After reviewing the variances we have identified: 1. Our process for labeling high risk meds has not been fully implemented 2. Medications orders were not properly stored 3. All rights of medication administration were not being followed. ACTION PLAN:Responsible Party Review the rights of medication administration DON Look Alike/Sound Alike medication storage will be identified with yellow labels with black lettering DON High risk medication storage areas will be labeled with red lettering DON High risk medication labels will be available in all medication preparation areas DON High risk medications will be transported in a specially identified container DON

42. Make it fun!

43. Questions? 43

44. Resources http://www.cdc.gov/injectionsafety http://www.apic.org/Resource_/TinyMceFileManager/Position_ Statements/AJIC_Safe_Injection0310.pdf https://www.aaahc.org/Global/pdfs/AAAHC%20Institute%20co ntent/aaahc_aeneid_report_FINAL.pdf http://cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_exhibit_3 51.pdf http://www.ihi.org/resources/Pages/Tools/ScrubtheHubPosters.aspx http://www.ismp.org/Tools/confuseddrugnames.pdf

45. Resources http://www.cdc.gov/niosh/docs/2012-150 http://www.oneandonlycampaign.org/ http://www.who.int/injection_safety/en/ http://www.jointcommission.org/standards_information/npsgs. aspx http://www.aorn.org/Secondary.aspx?id=26250&terms=medic ation