Successful Strategies in Medication Storage and Security

A look at this crucial patient safety and potential liability issue through an outpatient lens.

Medication safety can be a matter of life and death. The RaDonda Vaught case served as a wakeup call about the importance of keeping tight controls on the procurement and administration of sometimes dangerous drugs.

Often this issue is discussed in the context of a large hospital or health system. But medication safety — and its attendant patient safety and liability concerns — is just as relevant at outpatient facilities. The problem is most ASCs don’t possess the layers of specialized personnel and institutional checks and balances that most hospitals do — particularly in terms of in-house pharmacy professionals.

“Outpatient facilities typically don’t have the depth and breadth of pharmacy support you would see in an inpatient facility,” says Christina Michalek, BS, RPh, FASHP, director of the membership and patient safety organization at the Institute for Safe Medication Practices (ISMP) and administrative coordinator for the Medication Safety Officers Society. “Medication controls and safety issues are typically on the forefront of a pharmacist’s mind.”

Instead, many ASCs have no pharmacist on staff, and may rely on a consultant pharmacist. As a result, day-to-day practices in medication management can get a bit loose, with non-pharmacist practitioners thrust into medication safety leadership roles.

“There are checks and balances when a pharmacist is present,” says Dr. Michalek. “In an inpatient facility, there’s usually more prospective review of medication orders and use. In an outpatient facility, you may not have that at all, or it may just be retrospective. You may have other practitioner types operating as best as they can with their more limited knowledge of medications.”

So how can a lean ASC that lacks in-house pharmacy support best address medication safety?

Monitor medication news and research. “One of the best ways to prevent medication errors is to learn about errors that have happened elsewhere,” says Dr. Michalek. “Look for the most recent issues related to medication safety in the outpatient perioperative setting, and then evaluate your systems to see if they could happen in your location. If so, put prevention strategies in place.”

Focus on dangerous medications. “A number of medications are used routinely that ISMP would categorize as a high-alert medication,” says Dr. Michalek. “Examples would be neuromuscular blocking agents, some anesthetics and opioids — probably some of the most commonly administered medications in a perioperative setting.”

Medication safety is specialty-agnostic. “Anytime you give a medication, as benign as you think it may be, there is opportunity for error that can cause harm,” says Dr. Michalek.

Be aware of vulnerabilities. “Something that’s different in the perioperative environment is that, in many cases, medications are ordered, selected, prepared and administered by the same person,” says Dr. Michalek. “Typically, in other care settings, different practitioner types and different people would be involved in that process.”

Tech talk

Many inpatient hospitals have responded to these issues by implementing technology in perioperative settings, including automated dispensing cabinets, smart infusion pumps, bar coding and electronic health record integration. “The need to get medication safety technology in more outpatient facilities is there, but adoption has not caught up,” says Dr. Michalek. “There aren’t a ton of vendors out there, but I think they see that too. If surgery centers could implement some of these technologies, it will give them a higher-leverage strategy to prevent errors from reaching patients than just their providers’ personal vigilance.”

INCREASED PRECISION Using the electronic health records instead of paper record-keeping reduces the likelihood of medication errors.  |  Pamela Bevelhymer

Automated dispensing cabinets. Often considered too expensive for ASCs, Dr. Michalek says she has heard of some more cost-effective machines for outpatient settings. These cabinets can electronically track medications and provide controls that determine who can access them. “It facilitates safer storage and safer tracking of medications,” she says of these systems.

For some ASCs, however, the need for these cabinets isn’t acute — and as use of narcotics and opioids continues to decline in favor of multimodal pain management regimens and regional anesthesia, some ASCs are handling smaller supplies of dangerous drugs than they were five or 10 years ago.

Jen Jacobson, RN, is vice president of clinical operations and quality at Compass Surgical Partners, a full-service ASC management partner based in Raleigh, N.C. Although she has past experience with automated dispensing cabinets, they’re not a priority for Compass at this time.

“We don’t have them in any of our facilities,” she says. “They are starting to get to us slowly but surely, but I’m not going to lie — they’re still pretty expensive.” She notes that the data, alerts and reports these cabinets generate require extra administrative bandwidth. “If there’s a discrepancy, it goes on a log, so somebody needs to go in there to see what it was,” she says. “Did they count wrong? What happened? A lot goes into having them.”

The cost-benefit of automated dispensing cabinets isn’t yet compelling for Compass, which has embraced multimodal techniques. “In most of our ASCs, we’re doing total joints, so they’re doing spinal and a block, then using Zinrelef or Exparel,” she says. “The patients aren’t requiring a lot of medications in recovery. Our narcotics and other medications fit in a tiny cabinet. We have what we need, but don’t have a huge abundance like a hospital would.”

Smart infusion pumps. These electronic devices control the rate of medication administration to a patient electronically, as opposed to less specific traditional methods; Dr. Michalek provides the example of an IV bag of medication attached to an infusion tubing set, where a provider uses a roller clamp to compress the tubing and counts the drops that fall into a drip chamber to determine what might be the intended infusion rate. “An electronic infusion device provides increased accuracy and ease in setup, but a smart infusion device can alert users of potential errors in programming and stop administration of the drug outside programming limits,” she says. “Now you can say, ‘I want to infuse drug X at 50 mL/hr.’ If, by mistake, you touch the zero twice, the smart pump will record 500 instead of 50, but can alert you: ‘Hey, this is too high.’ You can also build smart pump library limits to prevent multifold overdoses.”

Dr. Michalek says smart infusion pumps also generate useful data. “You can see how many times people hit a soft limit or a hard limit,” she says. “A hard limit is a rate they can’t go past. A soft limit warns the provider that the rate seems a little high, and asks if they are sure this is the rate they want.” These controls can be drug-specific, and have been proven effective, she says.

Anesthesia providers at Compass ASCs use smart infusion pumps. Ms. Jacobson recommends selecting a manufacturer that will show providers the ropes. “We rely on the vendor to help us with the IFU so our providers learn how to give the medication and how the pump is supposed to be used — that it’s not just pushing buttons. To me, it’s another hard stop to make sure the patient is getting the correct dose. We are humans, and there’s human error. You can program this machine. You tell it how much the patient weighs, what the medication is, and it does the calculation for you.” However, the human factor remains crucial; Ms. Jacobson says Compass’ nurses also manually calculate the rate to confirm the machine has it right.

Bar-coding systems. Scanning the bar code of medications before administration provides another safeguard against human error. Dr. Michalek says these systems collect data that allow surgical leaders and administrators to monitor the number of incorrect scans.

Electronic health records. “These provide a much better record of what has transpired than paper records,” says Dr. Michalek. “Providers in the PACU can immediately see and easily identify the medications given — and when they were given — during surgery, as opposed to paper records that sometimes lag behind, can be incomplete or may not be easy to decipher.” She says the electronic record can also be set up to alert practitioners to potential errors, such as patient allergies.

Access control. Badge swipes, key cards, or just controlling who gets the keys to where medications are stored are essential security measures for surgery centers. Ms. Jacobson says Compass’ medication cabinets are only accessible via key codes or badge swipes. “Only the RNs have access to the cabinet,” she says. “We don’t even give the anesthesiologist access.” Cameras monitor the cabinet in the interest of identifying perpetrators of diversion or misuse. “We want to be able to know who’s getting into there, who’s pulling what,” says Ms. Jacobson.”

Dr. Michalek says what’s most important at any surgical facility, no matter what or how much supportive medication technology is in place, is the presence of a culture of safety. “Policies and procedures go a long way,” she says. “If there’s a policy that you report near misses, situations of concern and actual errors, and practitioners feel comfortable executing the policy, those issues can then be shared and discussed among all staff. Then, as a group, you can identify mitigation strategies.”

Reinforcing reduction strategies

A strong culture of safety grows in importance as more complex, higher-acuity cases move to ASCs. While medication safety technology can be expensive, its ability to reinforce and support strong error reduction strategies is proving increasingly vital.

“Vigilance alone is not going to sustain us,” says Dr. Michalek. “Any error regardless of harm can take a significant toll on clinicians. The ‘cost’ of an error — not only in dollars, but also reputation — can be devastating to an organization and the individuals involved.”

“We talk about medication safety a lot,” says Ms. Jacobson. “We have our huddles about it, and it’s not a hidden thing. If something is missing, we’re talking to everyone, we want to know what happened. We want everyone to follow our policies, and make sure we’re doing what we need to be doing.” OSM