During 2023, surveys of ambulatory surgery centers by Accreditation Commission for Health Care (ACHC) Surveyors revealed a variety of deficiencies. Some of the most common deficiencies found were related to the safety of drugs and biologicals. At any ambulatory surgery center, leadership has the ultimate responsibility to ensure that medications are always secure and will be provided safely and in an effective manner.

What exactly does that mean? ACHC Standards are specific in how your ASC staff should manage medications and records. Take a look at the standards below.

Standards 12.00.05: Controlled Substances
Standard 12.02.02: Security of Drugs and Biologicals

These standards require the ambulatory surgery center to have accurate records of receipt, storage, and current disposition. This means the ASC must track the movement of ALL scheduled drugs from the point of entry into the ASC until the point of departure. A documented process of accountability for these drugs must always be readily available.

It is important to include in your facility policy how drugs are to be counted when cases are not being performed.

• Scheduled drugs should be counted at the following times to minimize the risk of diversion:
  • Daily when staff members are in the building, even if there are not any scheduled cases.
  • Beginning and end of every day and/or shift.
  • When outdated drugs are being removed.
  • Whenever a delivery from a drug supplier is being received.
  • Whenever drugs are being added.
• Two licensed providers must witness counting and disposing of scheduled drugs in real time.

Scheduled drugs must always be kept under double lock. This can be accomplished using a locked medication room, a Pyxis MedStation automated medication dispensing machine, or double-locked cabinet.

Standard 12.00.07: Safe Administration Practices

Staff must follow safe practices when preparing and administering medications. Centers for Disease Control and Prevention guidelines help to decrease the risk of adverse events to patients.

• Always scrub the hubs with alcohol and allow the hubs to dry – even on new vials!!
• Medications drawn up by staff must be labeled with the contents, initials of the person who drew it, dose, date, and time.

Multi-dose vials must be used according to nationally recognized guidelines. Most importantly, once opened, multi-dose vials cannot be stored in patient care areas.

Standard 12.00.03: Drug and Biological Orders

This standard requires that medical records contain a complete and accurate account of ALL drugs ordered and administered to each patient. Organizational policies and Medical Staff bylaws should clearly define medication and treatment order requirements including who may order and who may administer in accordance with the ASC’s state laws and provider practice acts.

Remember: It is outside of nursing scope of practice to prescribe or make medical judgments. Orders must be complete enough so that no further medical judgment is required when the order is implemented. This means that a nurse cannot choose between two different medications ordered for the same purpose. Here’s an example:

• Order #1 – Fentanyl 25mcg every 5 minutes X 4 for PRN PAIN
• Order #2 – Dilaudid 0.5mg every 5 minutes X 4 for PRN PAIN

These orders are both for PRN pain, means the nurse must make further medical judgment. Therefore, these orders need further clarification. Here’s how they can be differentiated:

• Order #1 – Fentanyl 25mcg every 5 minutes X 4 for PRN Moderate PAIN
• Order #2 – Dilaudid 0.5mg every 5 minutes X 4 for PRN Severe PAIN

Remember to define pain levels within your policies. For example:

• Mild Pain – 1-3.
• Moderate Pain – 4-6.
• Severe Pain – 7-10.

A final reminder is to be sure that the ASC policy addresses the requirement for a patient’s pain to be assessed and documented before and after pain medication administration at intervals agreed upon by the medical staff. The Association of periOperative Registered Nurses (AORN) and the American Society of PeriAnesthesia Nurses (ASPAN) can provide guidance on best practice recommended intervals.

Here to Help

We are ready to assist. If you have questions or need help accessing ACHC’s most recent Accreditation Requirements for Ambulatory Surgery Centers, contact your Account Advisor, email [email protected], or call (855) 937-2242.