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Based on observations and interviews the facility failed to ensure staff adhered to accepted standards of practice related to the preparation and administration of medications in 1 of 1 observations.

The failure created the risk of healthcare-associated infections during the administration of intravenous (IV) medications.

FINDINGS

REFERENCES

According to the Association for Professionals in Infection Control and Epidemiology (APIC) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in HealthCare (2016), adherence to safe injection practices prevents the transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures. Perform hand hygiene before preparing or administering medications. Disinfect the rubber septum on all medication vials prior to entry, even after initially removing the cap of a new, unused vial.

According to the facility Medical Staff Regulatory Handbook (2016, p. 12), use proper hand hygiene and aseptic technique prior to drawing up and/or administering medications. Prior to entering any vial, bag, bottle or IV port, scrub the access stopper with alcohol or other approved disinfectant for 15 seconds. Do this even if a cap or cover is in place.

1. The facility failed to ensure staff maintained safe injection practices.

a) On 9/07/17 observations of clinical staff were conducted during the gastric endoscopic procedure of Patient #11.

Physician #1 performed administration of intravenous (IV) anesthesia to Patient #11 using an infusion line and pump designed to deliver the anesthetic automatically from a 10 millimeter (mL) syringe. At 8:35 a.m., Physician #1 removed a vial of Propofol anesthetic, removed the top and withdrew the medication into a 10mL syringe which was then connected to Patient #11's infusion line.

At 8:44 a.m. Physician #1 performed the same process for withdrawing additional Propofol anesthetic. S/he opened the new vial and withdrew the medication into a 10mL syringe then attached the syringe to Patient #11's infusion line.

Physician #1 was not observed disinfecting the Propofol vial stopper.

Between 8:55 a.m. and 8:59 a.m., Physician #1 was observed scratching behind his/her ears. No hand hygiene was performed by Physician #1 at that time. At 9:01 a.m. s/he obtained a third new vial of Propofol, removed the top, entered the vial without disinfecting the rubber stopper and withdrew the medication into a 10mL syringe which was then attached to Patient #11's infusion line.

b) An interview was conducted with Physician #1 on 9/07/17 at 10:04 a.m. S/he confirmed the vial stoppers were not disinfected with alcohol prior to withdrawing the Propofol. Patient #1 stated the disinfection of a new vial was not necessary because it was considered sterile when the top was first removed.

c) During an interview with Registered Nurse (RN) #2, on 9/07/17 at 10:01 a.m., s/he explained the facility practice for preparing and administering medications was to remove the top from the vial, scrub the vial stopper with alcohol then withdraw the medication. The practice was performed for infection control purposes.

d) The Clinical Manager (Manager #3) of the Post Anesthesia Care Unit was interviewed on 9/07/17 at 9:58 a.m. Manager #3 stated a new medication vial could be opened and medication withdrawn without disinfecting the stopper. According to Manager #3 the stopper only needed to be disinfected if it were a multi-dose vial which had been previously used. Manager #3 could not verify where s/he obtained the information that new medication vials did not require disinfection prior to withdrawing medication.

e) An interview was conducted with the Infection Prevention Manager (IPM #4) on 9/07/17 at 1:04 p.m. IPM #4 stated all staff received infection control training during orientation, at staff meetings, annual required trainings, newsletters and special topics were covered in safety huddles. S/he confirmed anesthesia staff were contracted and expected to follow all facility policies and procedures.

IPM #4 verified the observed practice performed by Physician #1 was inconsistent with standards of practice for injection safety outlined by professional associations like APIC. S/he expected all clinical staff to perform hand hygiene and disinfect the stopper of the medication vial, even if it was a brand new vial with a top. Disinfection of the newly opened vial was performed because "we don't know where they've been and there's a risk for bloodstream infections." IPM #4 stated s/he sent out an email training to all staff on the importance of disinfecting the stopper of medication vials.

The Director of Quality Management (DQM #5) was present during the interview and stated employed physicians were required to complete training modules but s/he was unsure if contracted physician groups were included in the requirement. DQM #5 stated s/he would try to locate the newsletter and email sent to physicians on safe injection practices.

f) At 3:23 p.m. on 9/07/17, DQM #5 provided the Medical Staff Regulatory Handbook (cited above) and stated the handbook was given to all physicians, including contracted physician groups, when hired. S/he added it was apparent retraining was needed to ensure everyone followed the correct process.