THIS THE ONE? Surgical team members must confirm the correct medication, dose and concentration before administering it.

I've helped many surgery centers prepare for accreditation surveys over the past 5 years, and observed how they store, label and administer medications. I've also observed common lapses that have occurred in various organizations. Here are a few tips for avoiding them.

DULY NOTED Pre-printed labels improve the accuracy and efficiency of identifying medications at the sterile field.

1. Use clear labeling
Tall-man lettering noted on medication labels helps differentiate sound-alike and look-alike drug names on vials, syringes and storage bins. Referencing the Institute for Safe Medication Practices' master list of confusing drug names (www.ismp.org/tools/confuseddrugnames.pdf), however, isn't enough to eliminate errors that may lead to serious consequences. Develop your own list of 10 look-alike and sound-alike drugs (tinyurl.com/d8hw6qj), targeting the medications used most often in your facility.

Pre-printed medication labels contain spaces where staff who are responsible for preparing pre-filled syringes may note their initials, the date and time, the drug name and its concentration. These fill-in-the-blank labels let you accurately and completely note medication information.

Customized labels, which come with dose and drug information already noted, ensure labels are easily read and standardized, and save your staff time when prepping for cases. Also consider using color-coded labels so your staff can easily differentiate various drug vials or pre-drawn syringes at the sterile field.

2. Organize storage areas
Keep look-alike and sound-alike drugs in non-adjacent storage bins or drawers so they're not easily confused when your staff pulls meds for a case. For example, don't store digitoxin (a cardiotonic glycoside) and digoxin (used to treat atrial fibrillation and flutter) next to each other, even if you organize drugs alphabetically. Also segregate pediatric and adult doses, various concentrations of the same drug and different drugs stored in similarly shaped vials with similarly colored labels.

Automated dispensing cabinets secure drugs, track drug usage and ensure correct doses are retrieved and properly labeled. On-screen prompts guide you to the proper medication and ask for confirmation if the requested drug is a high-alert medication for the patient for whom it's being requested.

Avoid over-ordering drug inventory. Many facilities I've consulted for have storage rooms filled with expired drugs. Keeping outdated drugs on hand is a dangerous and money-wasting practice. Set par levels to ensure you don't run out of needed medications, but also so you're not ordering more drugs than you can possibly use before they expire.

3. Promote proper use of single-dose vials
Single-dose vials may be entered only once, regardless of whether more medication is needed for the same patient. Unfortunately, drug shortages and increasing medication costs often prevent adherence to this basic requirement.

Single-dose vials of some widely used medications are in short supply — and cost more than larger doses — while other popular single-use medications (propofol in particular) are available only in large-volume vials with more than enough for use on multiple patients. Budget- and waste-conscious providers who don't want to discard unused portions of medications therefore re-enter single-use vials more than once, unaware of the ramifications.

Wanting to avoid wasting medication or to save money is understandable, but single-dose medications, unlike multi-dose containers, do not contain the preservatives necessary to prevent the growth of microorganisms. (Multi-dose vials generally have 28-day expirations unless the drug manufacturer says otherwise. Be sure to note the expiration date on multi-dose vials once they've been opened.)

Providers acknowledge that re-entering single-dose vials to obtain more meds may be wrong, but is done as a convenience and cost-saving effort, despite reports of bacterial infection outbreaks related to the reuse of single-dose vials that continue to occur.

Consider purchasing pre-filled syringes, which come properly labeled in ready-to-use, single-use doses that are disposed of as a unit. Pre-filled syringes may be a more expensive option, but you pay for convenience (your staff doesn't spend time drawing medications between cases) and peace of mind (cross-contamination risks are essentially eliminated). The added expense may be a factor in your facility, so prioritize which medications you want to purchase in pre-filled syringes. Your high-volume medications — the drugs administered during surgery as the rule rather than the exception — may be the most economical choice.

TRIALING TIPS

Are You Sharps Safety Compliant?

ON POINT Sharps safety protocols also promote safe injection practices.

OSHA requires the trialing and use of safety-engineered devices such as syringe needles that self-plunge, self-sheath or automatically retract. These devices also promote safe injection practices because they're disabled after use and can't be used on multiple patients. In my experience, however, at least 90% of outpatient facilities don't fully meet all the requirements of the Needlestick Safety and Prevention Act. That lack of compliance isn't rooted in willful neglect. Many administrators simply don't fully grasp what it takes to be fully compliant. Here are 3 keys to staying in OSHA's good graces:

1. When trialing safety-engineered devices, include a cross-section of your staff in the selection process. Non-supervisory personal must provide input; a single supervisor should not act alone to select the devices.
2. Many large healthcare organizations have a single committee interpret needlestick safety regulations and select devices for facilities under the heath system's umbrella. However, each facility should be represented in the decision-making process.
3. Don't shop for devices and conduct trials simply because it's required. If safety-engineered devices go unused at the front line, don't complain that your staff is noncompliant. Instead, reassess your trialing process and find devices that your staff and surgeons actually like.

Many improved, cost-effective safety-needle designs have hit the market in recent years, so it's time to take a second look if you haven't done so recently. Don't be scared away by the added expense. The ultimate costs of needlestick injuries or infection outbreaks far outweigh the additional dimes you'll spend for safety-engineered needles.

— Pamela Dembski Hart, CHSP, BS, MT, ASCP

4. Secure narcotics
Drug diversion, although unfortunate and not the rule, happens within the profession. Narcotics must therefore be secured at all times and never left unattended in ORs, recovery rooms or procedure areas. (Surveyors have noted and cited facilities for unattended narcotic-filled syringes during inspections.)

There are effective ways to store narcotics: in automated medication dispensing cabinets, which are ideal for keeping drugs secure, or in double-locked medication carts. If automated units are beyond your means, the storage cabinet you use must be secured to a wall and weigh at least 750 lbs., so it can't be lifted and walked out of your facility. Don't keep the key to locked medications in an unlocked drawer of the same storage cart.

5. Train effectively
Carve out time for training your staff on safe medication handling and injection practices, and provide them with the education and resources needed to properly label and store drug vials. Most centers touch on the topic once a year, which really isn't often enough, considering the amount of detailed information your staff needs to process and recall. Keep medication safety practices fresh in their minds by conducting quarterly or more frequent educational sessions.

Classroom-style teaching is best. Include PowerPoint presentations during educational sessions containing charts or graphs of compelling medication safety data (occurrences of outbreaks, for example), animated media and plenty of pictures to demonstrate both best practices and areas of needed improvement. Working with pictures is a compelling learning tool. Ask staff what's right or wrong about the action depicted, and discuss their feedback.

Conduct annual risk assessments of your medication management practices. Have you made significant changes to your facility's staffing structure or hired new employees? Have you added any new procedures? Have you changed the way medications are stored? All of these factors could impact how medications are ordered, stocked, delivered to the sterile field and administered.

6. Identify qualified leadership
Medication safety success is culture-driven, meaning your staff must buy into the concept. It also falls under many umbrellas: There's overlap between pharmacy, infection prevention and control, anesthesia and nursing. The ultimate oversight of these practices must rest on the shoulders of a qualified individual who's committed to safety and genuinely interested in improving the quality of care delivered in your center.

Identify a point-person who's ultimately accountable for your facility's medication safety practices, but delegate the person's responsibilities — inventory management, ensuring drug security, overseeing staff labeling practices — among several clinical staffers so no single team member is saddled with the burden. Teamwork is essential and creates increased buy-in of your medication safety policies. Shared responsibility is also key to achieveing successful accreditation survey results.