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SDS Accreditation Update
Biggest problem area for surgery centers? Maintaining records for waived testing
Last year, the highest area of noncompliance for ambulatory surgery centers accredited by The Joint Commission was Waived Testing 05.01.01, the organization maintains records for waived testing. It was the highest area of noncompliance for surgery centers. Eighteen percent of all ambulatory surgery centers were found noncompliant.
Element of Performance (EP) 3 says that the quantitative test result reports in the clinical record for waived testing are accompanied by normal values specific to the test, method (machine), and the population.
"For example, blood sugars would be accompanied by normal values specific to that test," says Virginia McCollum, MSN, RN, associate director of the Standards Interpretation Group at The Joint Commission.
There is a difference in the normal values for an adult population and a pediatric population, McCollum points out. "This [type of information] needs to be documented on the same page as the test result, or located somewhere within the permanent clinical records," she says.
Semi-qualitative results, such as urine macroscopic and urine dipstick, are not required to comply.
Surgery centers might be using references ranges for their labs, McCollum says. Reference ranges have to be specific to the machine and the test being performed, she says. For example, the reference range for a glucometer might not be the same as the reference range for another lab, she says.
Machines can be bought and sold, or replaced, McCollum says, but the reference ranges have to be specific to the machine being used. Usually the normal values can be placed in parenthesis on the report sheet, she says. "The solution is to do that where they record the waived testing," McCollum says.
You can add such information to your common tests, such as blood sugars, she says. "Once they put it on the form they use, they never have to think about it again," McCollum says.
This information has to be available in the record, she says. "But five years from now, you don't know `normal' for that machine at the time you did the test," she says. When blood is sent to a reference lab, the reply always has a reference range, but that range is related to the way the test is performed, McCollum says. "It's confusing, because it's often similar for the test," she says.
Also, staff should know who reviews the test results, what to do with the results that are out of range, who receives a report about out-of-range results, and what the response should be, sources say.
No. 2 problem? Labeling meds
Fourteen percent of surgery centers were noncompliant with National Patient Safety Goal (NPSG) 03.04.01 label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
EP 1 clarifies that the NPSG applies in perioperative and other procedures settings, both on and off the sterile field, and applies to medications and solutions that are not immediately administered.
If a medication is prepared or obtained and taken directly to the patient, and it's administered without any break in the process, you don't have to put a label on it, says McCollum.
However, this exception is strictly interpreted to mean no interruptions, says Elizabeth Norton, BSN, RN, CNOR, manager of OR patient safety and quality at Children's Hospital Boston. Norton spoke on patient safety at the most recent annual meeting of the Association of periOperative Registered Nurses (AORN). If a clinician gets stopped to have a conversation, or the phone rings, or they get distracted prior to administering a unmarked medication, that would cause a citation from The Joint Commission because that's an interruption, Norton says. In the OR, if a surgeon asks for specific medication that is not already on the sterile field, the medication can be drawn up and verified between the scrub and circulator, then handed to the surgeon for immediate administration to the patient, Norton says. That would be an exception to labeling. "However if there is time, it is always best practice to place the label," she says.
EP 2 clarifies that labeling occurs when any medication or solution is transferred from the original packaging to another container. All containers, including syringes, medicine cups, and basins, must be labeled, McCollum emphasizes.
Labels should include the full name of the medication/solution and the concentration, Norton says. Products that expire in less than 24 hours require expiration date and time, she says.
The Joint Commission has made a change to EP 3.
"Preparation date" was deleted from the list of information to include on medication or solution labels. The corrected EP reads: In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the following: medication name, strength, quantity, diluents and volume (if not apparent from the container), preparation date, expiration date when not used within 24 hours, expiration time when expiration occurs in less than 24 hours.
Challenges with labeling
There are multiple challenges with labeling, Norton acknowledges. One is compliance with medications that require the date and expiration time on drugs such as Propofol, which expires in six hours.
But in an ambulatory surgery center, if all of the cases are completed in less than six hours, it might not be necessary to label expiration time, she says. The center might opt to not require staff to put the date and time, because the drug will not expire during the procedure, she says.
Another challenge is compliance when only one solution is used and staff might think it is not necessary to label, Norton says. However, the no exceptions rule applies in this situation as well, she says.
A third challenge is staff compliance with the labeling requirement when the solution appears obvious, says Norton.
Sometimes your staff might ask why they have to label a product if it's the only solution that color. "I say no exceptions. When labeling, and you've transferred it, nothing is considered obvious," Norton says. "Everything must be labeled for patient safety. It's a Joint Commission requirement, and there's no getting around that."