You should expect more from your pharmacist consultant than a casual visit to stock your crash and anesthesia carts and to check for outdates. As medication use becomes more complex because of new drug entities and newly found indications and contraindications, you should rely on your pharmacist to keep you abreast of these changes and help with a strategy for safe medication use in your facility. Here are 14 services you should expect from your consultant.

1 Routine visits
I'm a consultant for 19 ASCs in the Las Vegas area. I visit each one, some weekly, some monthly, for as little as one hour to as long as four hours, depending on the size of the center, number of procedure rooms and medication storage areas, and my involvement in the medication-use and quality improvement processes.

During a routine visit, I'll review the narcotic requisitions, sign-outs, narcotic count and other medication acquisitions. I'll check for double-locks on narcotics and locks on other drugs when staff isn't in attendance. I'll check for medication organization, ensuring external meds are stored separate from internal meds. I'll make sure that refrigerators are at the appropriate temperature, that refrigerated meds are where they belong - in the refrigerator - and that no food has found its way into the med refrigerator. I'll also check to see that medications are properly labeled and within expiration limits.

2 Chart audits
Each month, I audit 10 percent of the charts for correct narcotic documentation. These routine audits have uncovered diversion and uncovered staff theft of controlled substances for personal use. With the statistics of addicted healthcare professionals well documented, this is an ongoing area of concern. The audits are also a good way to monitor prescribing trends. I also check for instances where staff gave medications patients were allergic to. The most common problem I find in this area is not a medication that has been given to the patient in the surgery center, but rather on a prescription written for fill after discharge.

3 Diversion reports
I've seen burglars, employees and patients steal medications. Whenever a narcotic disappears, you must file a report with your state board of pharmacy and the Drug Enforcement Agency (and, in Nevada, with the Nevada Department of Investigations). Each state's reporting requirements are different, and your pharmacist can assist with developing policy and procedure for reporting. Most important, your consultant can then work with you to review security to avoid future incidents.

Make sure you don't store medications in areas where patients can easily get at them, such as storing a few vials of anti-nausea medications, pre-op antibiotics and heparin flushes in an unlocked drawer near a patient area. Similarly, make sure you don't store crash carts in a patient area. I've found that the drug-seeking patient doesn't know what he's taking, but he'll take it anyway.

When several prescription pads recently came up missing from an ASC nursing station, we notified our state pharmacy board of the missing blanks. The board sent out a message on its hotline. The next day, we received a call from a pharmacist who stopped the filling of a fake prescription for OxyContin.

4 Controlled-substances audits
Every two years, the DEA requires that surgical centers audit controlled substances on or about May 1 of the odd year. We assist centers in compiling the report to keep on file along with copies of the DEA's form 222 in the event of a visit by the DEA. These audits are good starting points in the narcotics-tracking process.

5 Adverse drug events reports
We work with an adverse-drug-event report form at the centers to ensure the appropriate actions are taken to address the event. I review the actions taken; the quality improvement and medical executive committees also review the episode. We learn from these experiences by following up with staff education. Sometimes we address the process, and other times, staff members have been given refresher courses on topics such as calculating dosages.

6 Developing a formulary
The surgery center staff and I work to develop a formulary that's organized in both brand name order and generic order so the staff can use it to quickly cross-reference the brand or generic name of the drug. The formulary is kept at the nurses' station and in medication storage rooms for reference. We review and revise it annually to meet accreditation requirements.

7 Conducting in-services
I offer quarterly in-services on such topics as new drugs, JCAHO's patient safety guidelines, policy and procedure on abbreviations, look-alike and sound-alike drugs and how to compile an accurate list of medications that the patient is taking (see "Suggested In-service Topics").

8 Reconstitution of antibiotics
When I discovered that some of my centers were inconsistently (and sometimes erroneously) reconstituting antibiotics with different solutions, I created a one-page sheet of guidelines for appropriate reconstitution, route and rate of administration, and stability. These are posted in the medication room for quick reference.

9 Help finding items in short supply
Medication shortages, particularly for ASCs, have become a plague of sorts. Your consultant should help you find items in short supply, have them compounded when unavailable (if possible) and provide information on alternatives. When neuromuscular blocking agents were in short supply, we in-serviced staff on appropriate substitutions. In these cases of shortages, an excellent reference is www.ashp.org, the American Society of Health Systems Pharmacists Web site.

More frequently, it seems that manufactured medications are on the short supply list or are being discontinued by the manufacturer. A classic example of this is the spotty supply of Celestone. Two years ago, after having some issues with a compounding pharmacy that most of my centers were using for sterile products, I went on a nationwide search to find the best compounding pharmacy to supply the facilities (see "15 Questions to Ask Your Compounding Pharmacy"). Your consultant should ensure that the pharmacy that compounds your sterile products meets United States Pharmacopeia standards, has a documented quality assurance plan, and tests for composition, stability, sterility and fungal contamination.

10 Monitoring state and federal regulations
State pharmacy boards and licensing agencies, the DEA and accrediting agencies each have their own rules, which can seem like moving targets at times. Pharmacist consultants are obligated to monitor these changes and keep your facility abreast of any procedure changes you're required to make.

Here's an example. Some of my facilities were giving their cataract patients pre-packaged ophthalmic kits that contained prescription antibiotic, steroid ophthalmic drops and some supplies. Each time a center gave a kit to the patient, this constituted dispensing. But the medications weren't appropriately labeled for the patient, nor were the patients receiving appropriate counseling in all cases. Working with the pharmacy board, I developed acceptable policy and procedure, a limited formulary of medications that can be given to the patient at discharge and written counseling sheets backed by verbal nursing counseling.

11 Staying on top of accreditation guidelines
Learning from others' experiences is key to keeping current on important issues in inspections by the alphabet soup of accrediting agencies. As issues are unveiled, we share the information among centers, develop new policy and procedure as needed and hold in-services on these important topics.

12 Medication cost savings
Your pharmacist consultant should work with community pharmacies to supply items you don't need to purchase in larger prepackaged quantities. The crash cart is the primary example. Many of the emergency drugs are only available from the wholesaler in quantities of 10 or 25. Your consultant can find a pharmacy willing to split the package among centers, thus saving you dollars. You'll pay a little more per unit, but overall we've been able to cut the cost of the medications on the crash cart by nearly two-thirds. We also work with the nursing staff to consolidate storage areas and reduce duplicate inventory that might sit unused and subsequently expire.

Formulary decisions can help save money. We've targeted antibiotic use, anti-nausea medications and injectable steroids to help us save up to one-fourth of the cost of the medications used while maintaining safety and effectiveness for the patients.

13 Quality improvement
Attending quality improvement meetings and participating in the QI planning process are areas the pharmacist can be of great value to you. Two examples. First, we revised our policy and procedure on the time a patient would be monitored after use of the reversal agents Narcan (naloxone) and Romazicon (flumazenil). We're developing a prospective study to ensure that the change in policy helps us ensure that re-sedation is not an issue for the patients. Second, after a recent Medicare survey, we revised our P&P on outdated drugs and their disposition for the centers.

14 Address issues for special needs patients
Pediatric patients, the elderly, diabetics, patients with kidney disease and other special needs are often reviewed during in-services with staff to ensure we have the latest information about their response to medications and their special needs during surgery. As we know, one size doesn't fit all when it comes to surgical drugs. We've assisted in altering dosage forms, unit dosing liquid medications for pediatric patients, finding hard-to-find special items and researching information on myriad subjects.

A wise investment
The investment in your pharmacist consultant is money well spent. A good consultant is there to answer your questions, make time to help resolve your pharmacy issues and guide you in policy and procedure concerning medication use. The pharmacist can bring additional resources to the surgical services department you might have otherwise overlooked.