also has a list of them you can reference (osmag.net/S3zfYJ). You
also have to store these medications in a way that decreases the
chance of misuse. This can be as simple as putting a high-alert sticker
on the medication or even storing them in a big red box.
5. IFU access
This one is a common one. For all of your instruments and equipment,
you must be able to access the instructions for use (IFU). I remember
one facility I surveyed, I asked them where they kept their IFUs and
they looked at me like, "What are you even talking about?" If you
want to impress your surveyor, show her your notebook of IFUs for
your facility or, even better, show them that you have access to one-
sourcedocs.com. OneSource has access to every manufacturer's IFU,
and if they don't have it, you can request via email that they get it. But
if you can't swing that, just ask your sales rep for it. And don't just
trust what the vendor tells you about using the instrument. Ask for it
in writing. Just because 2 instruments are similar does not mean they
have the same sterilization process.
6. Impaired and incapacitated staff policy
What will your facility do if one of your surgeons has chest pains,
faints or becomes unconscious during a procedure? What about if one
of your nurses comes to work with alcohol on her breath or appears to
be under the influence of drugs? Many facilities believe their impaired
and incapacitated healthcare professional policies apply only to the
surgeon, but you need these policies in place for anyone in your facili-
ty, and particularly for those on your surgical team. The policies that
are clearest specifically address each healthcare professional and
what you should do when they are impaired or incapacitated.
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