Are you contracted with a pharmacist to come into your surgery center to perform periodic inspections for controlled substance review, medications storage, administering, waste and removal? You should. Medications management is a big part of your surgery center accreditation survey. Inspectors want to see that you are in compliance with adhering to National Patient Safety Goals. I want you to have a successful audit with your pharmacist so let’s get you prepared.
Make sure your surgery center policies and procedures pertaining to medications management are current to reflect the standards and what you are doing in your surgery center. Make sure you check CDC website periodically to stay current with Federal changes that have been made regarding multi-dose vials and safe injection practices. Make sure you label multi-dose vial with the expiration date (post 28 days from opening). Have on hand your controlled substance policies and procedures. Get the green light from your contracted pharmacist that your policies and procedures are compliant.
Demonstrate to your pharmacist who (MD, DO, RN, DPM) and how the authorized licensed staff member un-lock the narcotics cabinet. Make sure it’s a double locked cabinet.
The pharmacist will review your controlled substance log, crash cart medications log, anesthesia cart log and any other logs you have pertaining to medications that you have stored in your surgery center. The pharmacist will review that you are properly tracking your inventory and documenting waste of controlled substances.
Be prepared to go over with your contracted pharmacist techniques and identifiers you use to prevent medication errors. Make sure you are documenting the temperature of your medications refrigerator and to ensure that the temperature range is being monitored on a continuous basis. Remember the medications refrigerator is for storing medications only.
Here’s to your success,
NB
