Most Common Deficiencies For AAAHC Chapter 11 “Pharmaceutical Services”
The most common deficiencies our surveyors see for Chapter 11 “Pharmaceutical Services” of the AAAHC Accreditation Handbook for Ambulatory Health Care:
Injectable medications, if not given immediately, must be labeled with the drug name, strength, expiration date, and initials of staff who drew the medication.
There must be a written policy for the return or disposal of expired, damaged, or recalled medications and meet state law.
Expiration dates for crash cart medications and supplies should be checked and inventoried monthly.
Remember to check refrigerated medications monthly for expiration dates.
Once a multidose vial is taken into a patient area, it is then considered a “single dose” vial and cannot be used for multiple patients.
A list of “look-alike sound-alike” medications (present at the facility) must be posted. Consider posting the list on the inside door of the medicine cabinet.
“Look-alike sound-alike” medications should have some type of alert. Use red dots or order small alert labels. Separate them on the shelves.
The list of high alert medications (present at the facility) must also be posted.
To access AAAHC’s recent update addressing the impact of the coronavirus (COVID-19) pandemic on upcoming surveys, visit AAAHC Update
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience