When was the last time you examined your facility's medication safety practices? Don't wait for your next accreditation or regulatory survey: Grab a clipboard and use the following checklists below to gauge how well your facility and staff are complying with best practices in medication safety.

Controlled Drugs

• Withdrawals and returns of controlled substances from the PACU to the ORs (and vice versa) are tracked each day, with documentation of who handled which drugs and when.
• Power of attorney for controlled drug management is in place.
• Discards of all controlled drugs are witnessed by another licensed individual.
• Counts of the controlled drug cabinet are validated at the beginning and end of each day.
• The count of the controlled drug safe (if you have one) is validated at least monthly.
• Controlled drug documentation forms contain no erasures or Wite-Out.
• Invoices for controlled drugs are on file for 3 years (to enable audit if necessary).
• Controlled drug inventory (the "biennial"), due May 1 of each odd year, is in place and accessible.
• All "222" forms (orders for the highest level of controlled drugs, such as morphine and fentanyl) are completed with the date, quantity and initials of the receiving person noted on the right-hand side of the blue copy.

Emergency/MH Cart

• Carts checked at least monthly, preferably by different individuals, to validate contents/dates of drugs.
• All drugs maintained in the cart are within the manufacturer's expiration date.
• A label or list on the outside of the cart defines its contents (drug names, strengths and quantity stocked).
• Evidence in writing that your medical executive committee has approved the official list of the emergency cart contents.
• Cart contents accessible with "breakable locks" rather than key locks.
• Backup batteries for laryngoscope are within cart.
• If you serve pediatric patients, pediatric dosage guidelines and pediatric strength medications are available.
• Local or state poison control number is posted and easily accessible.
• Minimum of 36 vials of dantrolene are stocked in the malignant hyperthermia (MH) cart.
• At least 2,400ml of sterile water, without preservative, is stored with the dantrolene, preferably not in large plastic bags but in 100ml vials.
• The number for the MH Hotline — (800) 644-9737 — is readily available.
• If you have MH triggers, supplies of "cold" IV solutions and pour bottles of normal saline are maintained.
• New staff are trained on managing an MH crisis, and in-services for all staff are held at least annually.

Records and Documentation

• Verbal order read-back (VORB): Verbal orders are written down and repeated back to the prescriber.
• A list of "do not use" drug abbreviations is posted (download a list at www.ismp.org/tools/errorproneabbreviations.pdf); staff avoid using these abbreviations in medical records.
• Staff use military time listing consistently.
• Have a strong medication reconciliation system in place.
• Initials and signatures of staff who write in the medical record are archived so they're easily identified.
• Drug allergies are properly posted in the medical record, particularly on forms that order or record medication usage.
• Have documented evidence that the patient's current medication list is reviewed by anesthesia on admission (or the procedurist in endoscopy centers).
• Pain medication outcomes, specifically the results of medications administered post-operatively, are recorded.
• A record of discharge prescriptions is maintained.
• Pain assessments are documented upon admission and discharge of each patient.
• Pain medication orders have documented ceilings; for example, the maximum dosing allowed in terms of frequency and amounts.
• History and physical status (H&P) of patients conforms with existing CMS regulations.
• The designation "Keep Vein Open" (KVO) is amplified in the physician's orders to include IV rate and the specific solution.
• Use of generic drugs is embraced by your medical staff in its bylaws and/or individually approved by each authorized prescriber.
• Facility formulary is reviewed annually, endorsed by the medical staff leadership and memorialized in minutes of medical staff meeting.
• The compounding pharmacy with which you're contracted is specialized in sterile products and licensed in your state (if required).
• Pharmacy consultant has current license and evidence of liability insurance on file.

Safe Medication Practices (Clinical)

• Drug labels for pre-drawn medications have the 5 required elements: drug name, strength, date, time drawn into syringe and initials of preparer.
• Syringes are not pre-labeled en masse.
• Single-dose vials of drugs such as propofol are used for 1 patient only.
• Glass ampules are filtered.
• Sterile products, such as epinephrine in balanced salt solution, are prepared in a sterile environment, such as the OR, not at the nurse's station.
• A calibrated pump is available if you use drugs that require it, and staff are trained on how to use it.
• Reversal drugs, such as romazicon, naloxone and lipids (where applicable) are readily available.
• The "pre-spiking" of IVs is limited to 1 hour before use, and bags are labeled with the date and time of spiking.
• Multiple-dose vials are time-dated in accordance with the 28-day rule.
• Propofol with lidocaine is admixed just before need (not beyond 1 hour).
• Antibiotics are administered within 1 hour before the incision (in endoscopy, follow ASGE guidelines).
• Staff date succinylcholine and rocuronium when removing them from refrigeration, and adhere to manufacturers' guidelines for storage at room temperature.
• If you use benzocaine spray (in endoscopy), have at least 20ml methylene blue and a dosage regimen at hand.
• Sharps are disposed of in a sharps container that's replaced when the "fill line" is reached.
• Some sulfite-free propofol is in stock for patients allergic to sulfite.

Drug Storage/Environment

• Drugs are stored in properly lit and ventilated areas (not under sinks); storage rooms observe the 4" above floor and 18" below ceiling standard.
• Storage for medical gases is appropriately secured with individual chains.
• Carts and cabinets are locked when unattended.
• High-alert and look-alike/sound-alike medications are separated in drug storage areas.
• Do not have more than 1 strength of the same drug in stock, unless unavoidable, such as with various lidocaine combinations.
• Different types of drugs are not intermingled within a single compartment of a cart or tray.
• Drug samples are stocked securely, with a mechanism in place to track their entry into your facility and distribution to patients.
• Prescription pads are secured to prevent unauthorized access.
• Needles and syringes are stored securely and never unwrapped until needed.
• Medication refrigerator is lockable or in a locked medication room.
• Daily temperatures of the medication refrigerator are documented.