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With reports that the Centers for Medicare & Medicaid Services (CMS) told its surveyors to contact public health departments immediately if they see flagrant breaches of infection control, one surgery center has developed a new policy and procedure on infection control breaches.
CMS sent a memo to surveyors and listed concerns about unsafe injection practices and improper use of medication vials.1 The guidelines in the memo were effective May 30, 2014. (For more on the memo, see "CMS sounding alarm: unsafe needle practices — Specific reference made to ASCs and hospitals," Same-Day Surgery, September 2014, p. 91. To access the memo, go to go.cms.gov.)
"Upon reading the CMS memo, our team created a policy that says we will work cooperatively with state and accrediting organizations in identifying and monitoring any breaches and including the breaches listed in the CMS memo," says Mark Mayo, CASC, executive director of Golf Surgical Center, Des Plaines, IL. [The policy is included in this month’s online issue of Same-Day Surgery. To access, go to ahcmedia.com and select "Access Your Newsletters." You’ll need your customer number from your mailing envelope or your invoice. For assistance, contact customer service at (800) 688-2421 or email@example.com]
The following breaches were listed in the CMS memo:
using the same needle for more than one individual;
using the same (pre-filled/manufactured/insulin or any other) syringe, pen, or injection device for more than one individual;
re-using a needle or syringe that already has been used to administer medication to an individual to subsequently enter a medication container (e.g., vial, bag), and then using contents from that medication container for another individual;
using the same lancing/fingerstick device for more than one individual, even if the lancet is changed.
In the facility’s policy, Mayo referenced the importance of strictly adhering to the "One Needle/One Syringe /One Time" nationally recognized practice that is part of the "One & Only" campaign from the Centers for Disease Control and Prevention. (For more on the campaign, go to cdc.gov/injectionsafety/1anOnly.html)
Centers for Medicare and Medicaid Services. Infection control breaches which warrant referral to public health authorities. May 30, 2014. Web: go.cms.gov/1vlKKKw.