PERFECT SETUP This 'best of the best' cart was organized by Raj Mangla, MD, of Naugatuck Valley Surgical Center in Waterbury, Conn.

Our mantra is that we do what we do not for the survey, but because we know that a safe medication environment, propelled by continued vigilance, is one of the cornerstones of any facility's commitment to prioritize safety throughout the organization. If you observe "best practices" every day, survey day becomes just another day — one that requires no special preparation.

Not a week goes by in our practice without at least one of our facilities being surveyed by any of several overseers — whether it's a regulatory, licensure or accreditation review. We know that the anesthesia cart and how the provider manages drugs are among the most common concerns and areas of "survey vulnerability." More than ever before, we see a focus on how we do what we do at the anesthesia cart location.

How can you make sure survey day is just a routine day? By doing things well for the other 364 days a year. Here are 20 recommendations to help assure safe medication management within your anesthesia practice.

1. Organize carts for easy access.
2. Be sure to separate look-alike and sound-alike drugs in the cart.
3. Label all pre-drawn syringes with the industry-standard required labeling, as enunciated by accrediting and CMS overseers.
4. Be aware of drugs that require refrigeration and those that have a labeled room temperature guideline, such as rocuronium and succinylcholine. Label them with their expiration dates.
5. Remember that current guidelines say multiple-dose vials should be dedicated to a single patient whenever possible and that they should be discarded in patient-care areas after use.
6. Never use single-dose vials for more than 1 patient.
7. Be sure to discard drugs appropriately and make sure discarding of controlled drugs is witnessed in "real time."
8. No matter how tempting it might be to use it for multiple patients, use each propofol vial for one patient only.

9. Filter glass ampules with a filter needle.
10. Make sure your cart is always secured when it's unattended. The controlled drugs within it are the anesthesia provider's responsibility.
11. Don't unwrap syringes until you know you need them. And unwrap them as close to the time of administration as possible.
12. Use drawn syringes within 1 hour (unless they've been prepared in a laminar flow hood).
13. When you can use multiple-dose vials appropriately (see No. 5 on previous page) note the expiration date of 28 days (see "Know When Multi-Use Vials Expire at a Glance").
14. Ensure the information on the anesthesia record is legible and that doses are explicitly documented.
15. Be proactive about educating staff on such subjects as reversals with fat emulsions, naloxone, flumazenil and especially dantrolene.
16. Take responsibility for ensuring that the drugs and equipment within the anesthesia cart remain in date.
17. Review your med reconciliation responsibilities and be proactive in establishing a safe practice and policy for discharge medication guidance for patients.
18. Review the allergies patients say they have and know how their allergies interact with medications.
19. Be involved in the formulation of the code and MH cart formulary. Remember, you're the primary resource when it comes to managing patients who are in clinical jeopardy.
20. Ensure that antibiotics are administered according to current guidelines in relation to the incision time or start of procedure. Monitor dosing as appropriate and clearly document administration times.

MULTIPLE ERRORS These syringes aren't properly labeled. Also, they should be drawn as close as possible to the time of administration.	TOO CLOSE FOR COMFORT Look-alike and sound-alike drugs stored closely together are an invitation to disaster.
IT'S A WRAP Laryngoscope blades need to be properly cleaned and stored.	WHAT'S INSIDE? Are your gas tanks properly labeled at all times? They should be.