Given pharmacy’s constant challenge to institute appropriate distribution protocols for controlled substances in the stressful, fast-paced operating room environment, standardization is often the best approach to promote reliable accounting. Due to the high-risk, high abuse potential of medications used during anesthesia, Methodist Dallas Medical Center (MDMC) implemented a standardized anesthesia kit to help enhance control of drug distribution, personnel accountability, and patient safety.
In collaboration with the anesthesia and surgery and recovery departments, pharmacy designed a standardized process that provides medication access without adversely affecting patient care, minimizes controlled substances diversion, encourages accurate medical record documentation and patient billing, and ensures regulatory compliance. To test the effectiveness of the new system, we analyzed billing and financial data for two months prior to and following kit implementation. Anesthesia kit discrepancies, identified by pharmacist review, were also measured weekly for approximately three months following the implementation.
The Cycle of an Anesthesia Procedure Kit
At the outset, our anesthesia providers are required to follow proper procedure in selecting one kit per patient case from the controlled medication ADCs that house them and are accountable for each kit from removal to return to the ADC. Also, providers must document medication administration and any wastage in the anesthesia record. Likewise, assigned pharmacists are responsible for validating the anesthesia record against the returned kit to determine use vs waste of the products therein. They also validate the accuracy of refilled kits, complete and sign kit discrepancy sheets and wastage forms, co-sign kit inventory records, and perform random assays of waste produced. The third key responsibility is that of the pharmacy technicians who perform the initial review of the contents of returned kits and document any missing medications, refill appropriate contents for pharmacist check, return the filled and checked kits to the ADCs, and pick up any used kits.
After implementing the anesthesia procedure kit process, we ran the program for three months to obtain sufficient outcomes data. By comparing billing and financial data from the pre- and post-kit implementation periods, we found that the total medication charges per unit of service (inpatient and outpatient anesthesia) were similar—$250.78 and $253.25 respectively—and medication costs remained flat throughout. Due to the availability of generic products, the overall cost of controlled substances in the anesthesia procedure kits is lower than many other medications used during anesthesia. In addition, the percentage of discrepancies captured through pharmacist review trended downward over the three-month, post-implementation period, moving from 6.8% during week one to 2.7% by week 13.
Upon kit inventory review, our pharmacists categorized discrepancies into the following six categories: administration discrepancy, waste discrepancy, missing drug with no documentation, return bag not sealed, missing anesthesia record, and other. We found that most of the post-implementation discrepancies were related to drug waste (eg, inappropriate labeling of waste syringes, lack of documentation). As a result and through anesthesia provider and pharmacy collaboration, our medical records have been reconciled.
The new procedure has enhanced documentation of OR drug distribution and personnel accountability. Anesthesia medication documentation discrepancies have decreased, and the remaining discrepancies have been more easily resolved through collaboration.
Using anesthesia provider feedback, pharmacy is investigating the selection of a new kit container to help minimize medication breakage. Adjusting ADC par levels to enhance kit availability and working with providers to help ensure documentation accuracy is an ongoing effort. Through persistent review of medication use and waste patterns, the kit content can be modified as needed to further optimize operational efficiency and ensure continuous documentation accuracy.
Michael Chappell, RPh, is the pharmacy operations supervisor at Methodist Dallas Medical Center.
Ilka Ratsaphangthong, PharmD, BCPS, is the pharmacy clinical manager for MDMC.
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