Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
NOTES
■ Contrast media in the MRI suite, is stored in locked cabinets, however, the key for the cabinets is kept in an unsecured drawer. Contrast media is stored in the clean supply room in Radiology. Staff other than the technologists have access to this room. ■ In Surgical Services - In ORs: Multiple syringes of approximately 30 cc unused, unsecured propofol were observed. Multiple syringes and two vials of approximately 80 cc of unused, unsecured propofol, were observed. Multiple syringes of approximately 15 cc of unused, unsecured propofol were observed. Three vials of approximately 3cc of unsecured morphine were observed. ■ The hypothermia emergency cart was unlocked, allowing unauthorized staff to access the medication. ■ OB: The narcotic count for the automatic medication distribution unit was missing counts for five days in May, six days in June and on July 4th. ■ Partial vials of paralytic and of lidocaine were visible and accessible in red sharps containers. ■ The facility did not complete a risk assessment for medications stored outside of the pharmacy, nor did it have a policy defining authorized personnel permitted access to locked areas where drugs and biologicals are stored. Compliance tips for:
The standard is intended to support safe drug storage and to limit access to authorized individuals to avoid diversion. An area being prepared for a procedure or in which active patient care is being provided would be considered a secure area. An unstaffed patient care area requires controlled and non-controlled substances to be locked. ■ Add observation of medication carts, cabinets, and other storage and disposal boxes to environmental surveillance rounding. ■ Review how access to medication storage is managed, especially when drugs are stored with other items that require broad access. ■ Policies should delineate the proper disposal of medications by medication type and disposal container type. ■ Train staff and providers on proper disposal of unused drugs and conduct audits to promote accountability.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
CHAPTER 30: SURGICAL SERVICES
30.00.11 Surgical informed consent
See entry at 10.01.16 (pages 13-14).
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