ABC
GENERAL COMMENTS : SURVEY OF xxxxx, 2007
1] The findings of this visit were reviewed with xxxxi prior to our exit
2] NEXT REVIEW xxxxxxxxxxxx
, 2007
3] We have reviewed occurrences at ABC for the quarter and made
recommendations where appropriate
For the past quarter, there were no medication-related occurrences
requiring our review at ABC
4] PLEASE NOTE THE BEST AND FASTEST PHONE NUMBER TO REACH ME:
(860) 604 0014
5] REVISED POLICY OUTDATES OF MEDICATIONS
:
On the page which follows, we have revised the suggested
policy for “outdating” medications which have been opened
for use. We have customized it for your facility based on
our exit discussion
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ABC
Subject: Dating of Medications for Shelf Life After Initial Entry
Policy: The facility is mindful of the standards of best practice regarding the usage of
various products, including multiple dose vials (MDV), (which are designed for
repeated entry but are stable and best kept free of
pathogens with facility imposed outdating.)
Procedure:
Multiple Dose Vials
1] ABC will minimize the use of MDV except where necessary
2] Multiple Dose Vials are those vials so-labeled by the manufacturer
3] Entry into MDV shall be done using careful technique, including alcohol swabbing of
rubber stopper prior to use
4] The nurse or physician shall make a physical inspection of the MDV for second and
subsequent entries prior to entry
5] The vial is dated with the expiration date which shall be thirty (30) days after the
initial entry
6] The vial is deemed “outdated” by the 30 day rule, or, the manufacturer’s printed
date, whichever occurs first
7] Insulin vials and vaccines are an exception, deemed outdated 6 months after initial
entry. In addition, succinylcholine is 14 days when removed from the refrigerator and
Rocuronium (Zemuroin ®) is 30 days when opened and unrefrigerated and 60 days if
unopened/unrefrigerated
Ophthalmics
1] After the instillation of the first drop of ophthalmic solution from a multiple dose
container, the nurse or physician will date the container with the current date.
2] All ophthalmic solutions shall be deemed outdated thirty (30) days after initial entry
date, or the manufacturer’s expiration date, whichever occurs first..
3] The Clinical Nurse Manager, or his (her) designee, shall monitor and document that
this procedure is being followed and that the medication is handled in a suitable
manner
4] The consultant pharmacists shall similarly monitor for dating of multiple dose
solutions and occasionally for handling process.
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Topical Solutions and Creams/Ointments
1] All topical solutions will be dated with an expiration date when opened.
2] The expiration date will be the lesser of the manufacturer’s stated date or one year from
date of opening
Tablets and Other Oral Forms
1] The manufacturer’s expiration date will prevail for oral tablets
2] Oral solutions will be dated with the lesser of the manufacturer’s stated date or one year
from date of opening
3] Nitroglycerin tablets shall be deemed outdated 6 months after initial entry, or
manufacturer’s stated date is less than 6 month dating
Compounded Pharmacy Products
1] The Compounding Pharmacy’s expiration date posted on the product label shall be deemed
the expiration date
IV Solutions
1] The manufacturer’s expiration date shall be deemed the expiration date
2] IV Solutions will not be taken from their outer wrapper except if to be used within 48 hrs
In all cases noted above, the condition of the product, if in question, shall dictate immediate
replacement
4/05
Revised 12/06
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6] IV PUSH PROJECT
ABC should have an APPROVED IV PUSH POLICY developed. On exit
today, we discussed which drugs are given “IV Push” by the nursing staff
and suggest that the list be reviewed with the medical staff leadership for
approval
ABC
Policy: The medical staff has approved the intravenous
administration of the following drugs by “IV Push”
by the nursing staff:
________________________
_________________________
During our next review, we will be presenting a guideline booklet for drugs
in use at our centers and their recommended IV push rates
7] Emergency Cart Drawers
We have reviewed the labeling of the OUTSIDE of the Code Cart drawers
and list ABC
as compliant with this recommendation
We have reviewed the labeling of the Code Cart drawers and recommend
labeling as to general contents
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8] We have reviewed the current POINTS OF EMPHASIS
(Medication and Non-Medication Related) on exit. These reflect recent
survey recommendations by accrediting or State agencies
 Succinylcholine (Anectine® and Rocuronium (Zemuron®) should be
dated on your code and anesthesia carts as to when the expiration
date occurs after removed from the refrigerator
 Emergency lighting in Procedure Rooms
 Fire Drill Documentation. Building evacuation plans
 Estimated Blood Loss in dictations by MDs
 Are the codes on your cabinets and safes at “factory settings” ? (No is
a good answer)
 Pain level note on admissions
 For those who might need methylene blue for benzocaine-induced
methemoglobinemia, how much do we have on hand?
(Answer: minimum of 20 ml.)
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 Blanket warmer temperatures (Again!)
 Mannitol: 5 micron filter needle for preparation, 0.22 inline during
administration
 CD Players
9] Cost
in the OR
Containment Opportunity
Ondansetron (also known as a proprietary product
Zofran®) is now available generically at significant
savings. On exit, we have discussed strategies that
may result in ten-fold or more cost containment for
ABC
10] We have continued our discussion at ABC
regarding Reconciliation Preparedness and use of a
suitable tool to meet this standard expectation
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