Safe pharmaceutical practices in ambulatory surgery centers (ASCs) are essential to patient safety, regulatory compliance, and high standards of care.

ACHC Standard 12.00.03 stipulates that drug preparation and administration align with federal and state laws. This standard is frequently cited as a deficiency for a variety of missteps.

Common Issues: Small Corrections with Big Impact

Let’s look at three prevalent findings noted by ACHC Surveyors and what you can do today to ensure compliance with Standard 12.00.03 and other related standards.

1. Don’t: Leave Medical Records Unsecured
   Neglecting to secure presents significant security risks. And using pre-filled medication orders for distribution to all patients by nurses may result in incomplete patient records. Each of these issues raises liability concerns, and undocumented orders increase the risk of drug diversion and misuse.
   Instead: Maintain Vigilant Record Security
   Instruct your clinicians to input patient and treatment data directly into each patient’s medical record. This minimizes unauthorized access and ensures that each order is connected to a specific patient. Electronic health record (EHR) platforms should be password-protected, and paper-based medical records should be stored in locked cabinets with access limited to authorized personnel.
2. Don’t: Neglect Pain Management Protocols
   The absence of or inconsistent use of pain management protocols can lead to variable administration of high-risk drugs such as fentanyl. When not using clinical tools offering defined criteria as the basis for treatment, ASCs risk causing potential harm to their patients.
   Instead: Use Pain Management Scales
   Pain scales provide criteria that allow clinicians to accurately assess patient pain and consistently administer appropriate prescriptions. For high-risk medications such as opioids, defining specific dosing parameters can help mitigate risk of overmedication.
3. Don’t: Ignore Gaps Between Policy and Practice
   Surveyors frequently note conflicts between policies and practices in ASCs. One example is an ASC having a policy prohibiting range dosing and providers writing medication orders using such doses. A second example is a policy that prohibits the distribution of “sample drugs” to patients and practice that violates that prohibition.
   Instead: Review Policies and Practices Regularly
   Conduct annual reviews of policies. During these reviews, assess each policy for relevance, especially when changes are needed and when new medications or procedures are introduced. Audit practices to ensure alignment.