Top 5 mistakes staff are making during the accreditation physical inspections in surgery centers

So by our team being either present during the ASC physical inspections or by assisting the facilities at writing their corrective action plans, we see first hand the ridiculous and silly mistakes staff are making on the big day of the inspections. Below, we've outlined the top most common mistakes being made today that really should never have happened.


#1

CRNAs and RNs pull the top off the vial of medication, and inject the needle directly into the septum without? You guessed it. They failed to wipe the septum off with 70% Alcohol. Our jaws hit the floor below in disbelief. Seasoned nurses making this mistake and ignoring years of teaching, studies, outcomes fortified... why? I am not sure why they would be so relaxed in medication injection technique.


We all know that before you insert the needle, you must first wipe off vial top. This is a basic that every healthcare provider learns early on in clinical rotation, as well in pharmacy lecture classes. There is never an excuse that truly can redeem staff from making such a bold error.


The CRNA in this incident, she not only made the vial alcohol cleaning error, but she went onto make another mistake in not cleaning off the IV port before injecting propofol into the IV line. I mean how could this be happening? I don't understand it and neither did the surveyor. The inspector, a anesthesiologist no doubt, was so moved by her lazy response to her questions about dropping the standard of care so much lower than it needed to be lowered. The surveyor wrote her up and submitted the report to both the nursing boards and the CRNA boards. She now is suspended, her license is in suspense waiting the committees final disposition and ruling for her mishaps. This is serious stuff folks, it should not be taken so lightly.


#2

Anesthesia Providers fail to be in appropriate attire when in the operatory space/rooms. The incident involved a physician whom had a history of not wearing head coverings during the procedures. There was a file 3 inches thick from management, Chair of the Governing Body, etc., outlining this behavior of this physician. Where the mistake really takes a turn for the worse is for the facility. You see, the facility had done the correct oversight of this problem by writing him up and documenting these events as they should have. The problem lies in that the problem never got resolved nor did the situation get mentioned in the reappointment of the center privileges the provider got renewed every three years, still no problem or issues identified such as this behavioral issue that had become uglier and uglier each three-year cycle. The surveyor noted that this issue with the provider had been given to the management prior survey, it was noted that he had done the same thing and they (the accrediting body) forewarned the facility to address it or get him off staff. They did nothing. This is a huge problem now for the facility, it shows that the oversight and responsibility it has for the medical staff is invalidated. Serious stuff, folks!



#3

High-risk medical equipment must be checked at the beginning of the shift prior to any incision being made to ensure it works properly and it is documented that the verification was done. This did not occur in three of four centers since Jan. 2022.

All of us in the operating room know that this must be done,

but for one facility they re-wrote their policy to where it was checked monthly. This is not one of the standards that you set, and then must maintain your own goal established. This is a minimum standard under emergency management of the patient that cannot be slighted or downgraded. This does not work; needless to say, this fell under life and safety and they might very easily lose their Medicare Deem Status over this silly mishap. Bad for them, folks.


#4

NO smoking signs. There are facilities out there that continue to fail when it comes to ensuring that their patients know that "no smoking is permitted, mainly because of the presence of O2." Why do we turn a blind eye to obvious standards that are so easy to demonstrate compliance. This takes a simple sign, posted in the lobby. That is it, nothing more. So simple, yet failures here and there throughout Southern CA.


#5

Failing to process NPs and PAs like you do the physician credentialing process. They must be processed like the physicians are, no doubt about this standard. Just like your registry staff would be processed like regular full time/part time staff. These are the expectations of the accrediting org. Now that you know they must be processed this way, it's time to do the right thing and process them as you know to do.






















































































































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