Critical Access Hospitals Site Visit Summary Tom Johns, PharmD, BCPS Director, Pharmacy Services UF Health Shands Hospital

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1 Critical Access Hospitals Site Visit Summary Tom Johns, PharmD, BCPS Director, Pharmacy Services UF Health Shands Hospital

2 Critical Access Hospitals (CAH) Site Visits Compounded Sterile Products Offsite Medical Staff Offices Structured Assessment Tool: Radiology/CT OR/Procedural area Malignant hyperthermia cart 2

3 Operating Room/Procedural Area 3

4 Malignant Hyperthermia Cart 4

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46 Completed Recommendations Implement a reliable strategy to ensure opened multidose injectable vials contain the expiration date or discard after each use to reduce the risk of contamination. Reinforce existing program to ensure that single-dose injectable vials (SDV), containing no preservatives, are NOT stored and reused after opening. Ensure each bin in the mobile medication cart contains patient room numbers. We noted some blank drawers containing medications. We re concerned about the ease of causing wrong patient mediation errors, especially Bed A and Bed B mistakes. 46

47 Completed Recommendations Evaluate current medication administration policy and procedure to ensure it results in a consistent, standardized process. Variability currently exists in utilization of a printed MAR for medication retrieval from Omnicell. This printed MAR could easily become outdated as new medication orders are placed into the system, which could lead to error. Develop a P&T Committee approved policy to allow the Pharmacist to automatically enter PRN indications for medications devoid of the indication in the original order. For example, if the Pharmacist reviews an order for morphine that does not contain a PRN indication, the Pharmacist may rewrite the order to read PRN severe pain per P&T Committee authorization. 47

48 Completed Recommendations Based on ISMP recommendations, we encourage the hospital to modify the contrast screening form and patient instruction form to include all brand names of medications containing metformin. Obtain adult emergency drug references and place on emergency carts located in the ED. Replace outdated Broselow tape with the current 2011 version A. 48

49 Completed Recommendations Recommend removal of succinylcholine from the inpatient medication refrigerator to avoid the risk of retrieval errors. Add a staff Nurse to the membership of the Medication Safety Committee. Recommend that Pharmacist directly stock the ED medications into specific bins upon delivery to the area, rather than rely on Nursing staff for this activity. 49

50 Completed Recommendations Standardize anesthesia trays and maintain by the Pharmacy. We encourage focus time in this area during OR procedures to observe labeling practices by anesthesia providers. Complete the ISMP quarterly action agenda and incorporate into the minutes of the Medication Safety/P&T Committee meetings. Recommend adding a continuous pulse ox order for any patient receiving basal PCA throughout the admission. In addition, the hospital should evaluate risk reduction strategies for any patient receiving PCA therapy with obstructive sleep apnea as a co-morbidity. 50

51 Completed Recommendations Purchase and install a commercial Malignant Hyperthermia cart for use in the OR. Stock sterile water vials (instead of bags) in the Malignant Hyperthermia cart for each vial of Dantrolene. Re-evaluate and improve temperature monitoring of all medication refrigerators in the hospital. Develop a surveillance system for routinely inspecting offsite medication storage areas. 51

52 Completed Recommendations We encourage the purchase of an automated dispensing cabinet within the Pharmacy to enhance controlled substance security. 52

53 New Recommendations Lock prescription paper similar to any controlled substance. Develop and implement a policy to limit Restoril dosing in elderly patients to 7.5mg. Discontinue the practice of storing a bulk bottle of phenytoin in the inpatient medication room for dispensing by Nursing staff. We recommend the Pharmacy unit dose a standardized dose (e.g. 100mg) into syringes for dispensing. 53

54 New Recommendations Redesign current radiopharmaceutical compounding area to meet requirements of Florida BOP. Obtain and evaluate intelligent IV pump CQI to determine improvement opportunities related to soft and hard stop warnings presented to the end user. Obtain Special Limited Community Pharmacy permit to authorize dispensing of select prescriptions from the ED or inpatient nursing unit. 54

55 New Recommendations We recommend deactivating the current pediatric/adult scales in the ED and all patient beds to only weigh in metric units. Implement a morning safety huddle led by senior hospital leadership. The intent is to share potential safety opportunities that have occurred within the previous 24 hours. Discussion topics could include staffing issues, equipment failures, medication errors, falls, etc. 55

56 New Recommendations Delete all combination narcotic/acetaminophen products from the Formulary. In addition, delete hydrocodone from the Formulary. We recommend a single ingredient strategy to decrease the risk of inadvertent acetaminophen overdose. The hospital should only stock oxycodone and acetaminophen as individual ingredients. Conduct one medication-related FMEA during the next 12 months. Recommend development and implementation of a program to ensure proper aseptic technique is utilized when reconstituting a sterile injectable medication vial. 56

57 Additional Findings We re unclear why the Pharmacy Department is currently stocking and dispensing dietary supplements. We recommend moving these products to the dietary department. Discussed creation of a policy to prohibit medications from being stored in packets. Consider creating relationship with closest College of Pharmacy and serving as a training site for IPPE and APPE students. 57

58 Comments? 58