Perioperative Medication Safety Self-Assessment for Hospitals and Ambulatory Surgical Centers and Targeted Risk-Reduction Tool Development (CDER)

1

ISMP Medication Safety
Self Assessment
for Perioperative
®

Settings

Assess
Measure
Improve
Document
Progress

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Contents

Invitation to Participate .................................................................................................................................... 3
Funding Source, PRA Burden Statement, and Security of Information ................................................. 4

Purpose, Audience, and Scope ....................................................................................................................... 5
Acknowledgements .......................................................................................................................................... 6

Endorsing Organizations .................................................................................................................................. 7
Key Definitions ................................................................................................................................................... 8

Key Abbreviations ............................................................................................................................................. 9

Instructions for Conducting the Self Assessment .................................................................................... 10
Instructions for Entering and Submitting Information to ISMP ............................................................ 13

Demographics .......................................................................................................................................... 16
(20 questions for hospitals, 19 questions for freestanding ambulatory facilities)

Key Element I: Patient Information ........................................................................................... 31
(1 Core Characteristic, 25 assessment items)

Key Element II: Drug Information .............................................................................................. 35
(1 Core Characteristic, 18 assessment items)

Key Element III: Communication of Drug Orders and Other Drug Information.......... 38
(1 Core Characteristic, 21 assessment items)

Key Element IV: Drug Labeling, Packaging, and Nomenclature ....................................... 42
(2 Core Characteristics, 22 assessment items)

Key Element V: Drug Standardization, Storage, and Distribution ...................................... 46
(4 Core Characteristics, 47 assessment items)

Key Element VI: MEDICatION DELIVEry DEVICE acquisition, Use, and Monitoring ............... 55
(1 Core Characteristic, 16 assessment items)

Key Element VII: Environmental Factors, Workflow, and Staffing Patterns ................ 58
(2 Core Characteristics, 11 assessment items)

Key Element VIII: Staff Competency and Education ............................................................. 60
(2 Core Characteristics, 11 assessment items)

Key Element IX: Patient Education ............................................................................................ 62
(1 Core Characteristic, 8 assessment items)

Key Element X: Quality Processes and risk Management ................................................. 64
(4 Core Characteristics, 40 assessment items)

Glossary ................................................................................................................................................................ 70

About the Institute for Safe Medication Practices (ISMP) ........................................................................... 76

Logos of Endorsing Organizations................................................................................................................... 77
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Invitation to Participate
Dear Healthcare Provider,

The Institute for Safe Medication Practices (ISMP) is pleased to provide our nation’s healthcare providers with the
ISMP Medication Safety Self assessment® for Perioperative Settings. This tool, funded by the US Food and Drug
Administration (FDA), offers hospitals, freestanding ambulatory surgery centers, and other facilities that perform
outpatient medical and/or surgical procedures a unique opportunity to assess the safety of systems and practices
associated with medication use in the perioperative setting.

The assessment items were assembled by ISMP working with an expert Advisory Group to ensure that the systems
and practices most critical to perioperative medication safety were included and achievable in many healthcare
facilities. As with our past ISMP Medication Safety Self Assessment® tools, many key organizations have endorsed or
supported the ISMP Medication Safety Self assessment® for Perioperative Settings and offered their ongoing
support of this important endeavor. Our endorsers’ names appear on page 7, and their logos appear on the back
page and on our website.

Healthcare facilities that complete the assessment will be able to identify specific challenges and opportunities for
improvement as well as track their experiences over time. Use of the self assessment will also help providers
document compliance with risk assessments and performance improvement requirements from various state and
federal regulatory agencies, such as The Joint Commission and the Centers for Medicare & Medicaid Services.
Healthcare facilities that submit their assessment findings to ISMP anonymously via a secure internet portal by april
30, 2021, will also be able to obtain weighted scores for each item based on their effectiveness in reducing the risk of
perioperative medication errors, as well as access aggregate data to compare their individual experiences to the
aggregate experiences of demographically similar healthcare providers.

As with the data submitted by thousands of healthcare providers in response to our prior ISMP Medication Safety Self
Assessment® tools, we will use the aggregate findings to develop tools and plan curricula and other means of
support to assist you in enhancing perioperative medication safety. Additionally, an analysis of the aggregate results
will be submitted for publication in a professional journal to detail our nation’s baseline efforts to prevent patient
harm from medication errors in the perioperative setting.
ISMP, FDA, and the endorsing organizations encourage you to participate in this very important endeavor by
completing the self assessment as directed in the instructions and by submitting your findings anonymously to ISMP.
We welcome the opportunity to work with you as you assess the safe use of perioperative medications in your
organization!

Warm regards,

Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon), FASHP
President
Institute for Safe Medication Practices

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Funding Source
This project has been funded by the US Food and Drug Administration (FDA) under contract # 75F40119C10120. All
materials associated with this project represent the position of ISMP and not necessarily that of the FDA.

PRA Burden Statement
According to the Paperwork Reduction Act (PRA) of 1995, an agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control/number.
The valid OMB control/number for this information collection is 0910-0847 and the expiration date is 12/31/2022. The time
required to determine eligibility to use the assessment is estimated to average 2 minutes per person, and the time required
for small teams to complete this information collection is estimated to be 8.54 hours for Ambulatory Surgical Centers and
25.67 hours for Hospitals.

Security of Information
Security of Participant Information

Your participant information will remain secure to the extent permitted by law, and your personal identifying information
will not be included in any reports.

Security of Self-assessment Findings Submitted to ISMP

All information submitted to ISMP is stored in a secure database maintained solely by ISMP. All information is submitted
anonymously, and organizations can expect the usual high standard of confidentiality associated with any information
submitted to ISMP.

Although demographic information is collected as part of the assessment process, ISMP will NOT be able to identify
individual facilities that have entered and/or submitted information. Furthermore, the ISMP database does not allow
viewing of demographic information associated with individual assessment information. All information is contextually
de-identified, and the demographics are used only for aggregate data reports. Usernames and passwords required for
submitting information to ISMP are created by the facilities and can be as non-descriptive as desired by the organizations.
For additional information, see the Instructions for Entering and Submitting Information to ISMP beginning on page 13.

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Purpose
The ISMP Medication Safety Self assessment® for Perioperative Settings is designed to:

Heighten healthcare providers’ awareness of best practices associated with safe medication systems in the perioperative setting
Assist healthcare providers with identifying and prioritizing gaps in perioperative medication systems to avoid patient
harm
Analyze the current state of medication safety in perioperative settings and the challenges healthcare providers face
in implementing best practices
Create a baseline measure of national perioperative medication safety efforts

The self assessment is divided into ten Key Elements that significantly influence safe perioperative medication use. Each Key
Element is defined by one or more Core Characteristics that further define a safe perioperative medication use system. Each Core
Characteristic contains individual self-assessment items to help you evaluate your success with achieving each Core Characteristic.

ISMP is not a standards setting organization. As such, the self-assessment items in this document are not purported to
represent a minimum standard of practice and should not be considered as such. In fact, some of the self-assessment items
represent innovative practices and system enhancements that are not widely implemented in perioperative settings today.
However, their value in reducing errors is grounded in scientific research and/or expert analysis of medication errors and
their causes in the perioperative setting.

The ISMP Medication Safety Self assessment® for Perioperative Settings and its components are copyrighted by ISMP
and may not be used in whole or in part for any other purpose or by any other entity except for self assessment of perioperative medication systems by healthcare facilities as part of their ongoing quality improvement activities. The aggregate
results of this assessment will be used for research and educational purposes only.

Audience (Eligibility to Participate)

The ISMP Medication Safety Self assessment® for Perioperative Settings is intended to help healthcare providers
assess their current status and measure their progress in implementing best practices associated with perioperative medication safety. The tool is specifically intended for use by:
Hospitals that perform inpatient and/or outpatient medical and/or surgical procedures
Freestanding ambulatory surgery centers, including those dedicated to gastrointestinal/endoscopy procedures
Other facilities that perform outpatient medical and/or surgical procedures

Scope

Unless otherwise stated, the assessment items in the tool pertain to the perioperative processes, staff, equipment, technology, environment of care, and/or medications associated with medical and/or surgical procedures and the patients who
undergo them. For the purpose of this assessment, a medical and/or surgical procedure is defined as any procedure performed on a patient by a licensed healthcare practitioner that requires MODEratE SEDatION, DEEP SEDatION, MONItOrED
aNEStHESIa CarE (MaC), rEgIONaL aNEStHESIa, and/or gENEraL aNEStHESIa, including diagnostic and INVaSIVE PrOCEDUrES* that meet
this definition. Excluded from this assessment are procedures that require minimal sedation—a drug-induced state that
does NOT affect the patient’s airway reflexes, ventilatory and cardiovascular functions, or their ability to respond to verbal
commands. Also excluded from this assessment is the care of patients after they are discharged home or transferred out
of the perioperative setting, usually to an inpatient hospital bed.
*Terms in bOLD, SMaLL CaPItaL LEttErS are defined terms that can be found in the glossary (page 70).

Detailed instructions for conducting the assessment can be found starting on page 10.
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Acknowledgements
advisory group

ISMP thanks the following members of our voluntary Advisory Group, who helped inform the content of the
ISMP Medication Safety Self assessment® for Perioperative Settings.
Julie boytim, DNP, CrNa
Perioperative Medication Consultant
Performance Anesthesia Services
College Station, TX

Mary burkhardt, MS, rPh, FaSHP, FSMSO
Pharmacist
VA National Center for Patient Safety
Ann Arbor, MI

byron burlingame, MS, bSN, rN, CNOr
Senior Perioperative Practice Specialist
Association of periOperative Registered Nurses (AORN)
Denver, CO

t. Forcht Dagi, MD, DMedSc, DHC, FrCSEd, Mba, MPH,
FaaNS, FaCS, FCCM
Professor
Queen’s University Belfast, Northern Ireland
Newton Centre, MA

rosemary Duncan, PharmD, bCPS
Medication Safety Officer, Adults
The Johns Hopkins Hospital
Baltimore, MD

Eliot grigg, MD
Associate Professor
University of Washington/Seattle Children’s Hospital
Seattle, WA
gail Horvath, MSN, rN, CNOr, CrCSt
Senior Patient Safety Analyst and Consultant
ECRI
Plymouth Meeting, PA
Joshua Lea, DNP, Mba, CrNa
Certified Registered Nurse Anesthetist
Massachusetts General Hospital
Boston, MA

ronald Litman, DO, ML
Pediatric Anesthesiologist
Children’s Hospital of Philadelphia
Philadelphia, PA

Lauren M. y. Lobaugh, MD, MaS, FaaP
Assistant Professor
Department of Anesthesia, Perioperative, and Pain Medicine
Baylor College of Medicine/Texas Children’s Hospital
Houston, TX
tricia Meyer, PharmD, MS, FaSHP, FtSHP
Adjunct Associate Professor of Anesthesiology
Texas A&M College of Medicine
Baylor Scott & White Medical Center – Temple
Temple, TX

ann Shimek, MSN, bSN, rN, CaSC
Healthcare Executive, Independent Consultant
Executive Director ASC Quality Collaboration
AShimek Clinical Pathways
Dallas/Fort Worth, TX

Sheldon S. Sones, rPh, FaSCP, bS Pharm
President
Sones and Associates
Newington, CT

Deborah Wagner, PharmD, FaSHP
Clinical Professor Anesthesiology/Pharmacy
Pediatric Safety Coordinator
Michigan Medicine
Ann Arbor, MI

rachel Stratman Wolfe, PharmD, MHa, bCCCP
Perioperative Clinical Pharmacy Specialist
Barnes-Jewish Hospital
St. Louis, MO

Nicole yin, PharmD
Pharmacy Supervisor, Perioperative Services
M Health Fairview/University of MN Medical Center
Minneapolis, MN

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Organizations That Have Endorsed the
ISMP Medication Safety Self Assessment® for Perioperative Settings
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

American Association of Nurse Anesthetists (AANA)

American Society for Health Care Risk Management (ASHRM)

American Society of Health-System Pharmacists (ASHP)

Anesthesia Patient Safety Foundation (APSF)

Association of periOperative Registered Nurses (AORN)

Children’s Hospitals’ Solutions for Patient Safety (CHSPS)

ECRI

Infusion Nurses Society (INS)

Institute for Healthcare Improvement (IHI)

National Association of Healthcare Quality (NAHQ)

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Key Definitions (for the purposes of this self assessment)
Caregiver: A family member, friend, or other person not providing patient care on behalf of the healthcare facility, who is
assisting the patient with medication administration, particularly in the home, or monitoring the patient’s adherence to
instructions.

Close call: An error that was detected and corrected before it reached the patient.

guideline: Recommendations that provide acceptable practices and options, including drug therapy, for managing a
particular procedure or treatment for a specific diagnosis or condition, which can be used to assist in clinical decision
making and adapted to the patient’s specific needs.

High-alert medications (or drugs): Medications that bear a heightened risk of causing significant patient harm when they
are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are
more devastating to patients. Examples of high-alert medications include insulin, opioids, neuromuscular blocking agents,
anticoagulants, and many others. A complete list of high-alert medications used in the acute care setting (also appropriate
for outpatient perioperative care settings) can be found at: www.ismp.org/node/103.

Medical and/or surgical procedure: Any medical and/or surgical procedure performed on a patient by a licensed healthcare practitioner that requires MODEratE SEDatION, DEEP SEDatION, MaC, rEgIONaL aNEStHESIa, and/or gENEraL aNEStHESIa, including
diagnostic and INVaSIVE PrOCEDUrES that meet this definition.

Medication (or drug): Medication includes: prescription medications; sample medications; herbal remedies; vitamins;
nutraceuticals; over-the-counter drugs; vaccines; diagnostic and contrast agents used on or administered to persons to
diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments;
parenteral nutrition; blood derivatives; IV solutions (plain, with electrolytes and/or drugs); and any product designated by the
US Food and Drug Administration (FDA) as a drug. The definition of medication does NOT include enteral nutrition solutions
(which are considered food products); oxygen and other medical gases; cannabis; and illicit drugs unless explicitly stated.
Neonate (or neonatal): A newborn infant up to and including 1 month old.

Order set: Standardized list or template of logically grouped medical orders used to treat specific clinical situations (e.g., a
specific diagnosis, a specific drug therapy), which follow pre-established clinical guidelines based on evidence-based best
practices. The use of order sets can decrease variation in care; enhance compliance with recommended treatment guidelines;
promote complete, unambiguous, and accurate orders; reduce the risk of prescribing errors; and improve patient outcomes.

Pediatric: An infant older than 1 month to children and adolescents up to young adulthood.

Perioperative: The preoperative, intraoperative, and postoperative phases of a medical and/or surgical procedure, extending from the time a patient is prepared for a procedure until he or she is discharged home after the procedure or transferred out of the perioperative setting, usually to an inpatient bed.

Practitioner: A licensed healthcare professional who is authorized within the institution to prescribe, dispense, or administer medications, such as a physician, physician assistant, CRNA, anesthesiologist assistant, nurse practitioner, nurse
(including circulating nurse, scrub nurse), perfusionist, pharmacist, or respiratory therapist.

Protocol: A defined, standard regimen intended to be followed for managing a particular procedure, drug therapy, or treatment for a specific diagnosis or condition, which often includes medication precautions and dosing instructions, supportive
treatments, and patient monitoring.
aDDItIONaL gLOSSary tErMS

Additional defined terms can be found in the glossary (page 70) and are designated throughout the text in bOLD, SMaLL

CaPItaL LEttErS. In the online version of the assessment, these additional terms are linked to their definitions when they

appear in a demographic question or self-assessment item.

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Key Abbreviations
aCLS
Advanced cardiovascular life support

aDC
Automated dispensing cabinet (also known as automated
dispensing device or machine)

aSC
Ambulatory surgery center

CPOE

COMPUtErIzED PrESCrIbEr OrDEr ENtry

CrNa
Certified registered nurse anesthetist

EHr
Electronic health record (or electronic medical record)

FaQ
Frequently asked question

IM
Intramuscular(ly)

IV
Intravenous(ly)

MaC

MONItOrED aNEStHESIa CarE

Mar
Medication administration record

NPO
Nothing by mouth (nil per os)

PaLS
Pediatric advanced life support
PCa
Patient-controlled analgesia

PCEa
Patient-controlled epidural analgesia
PrN
As needed (pro re nata)

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Instructions for Conducting the Self Assessment
It is important that each facility within a multifacility system complete the self assessment
individually. FAQ

1. Establish a team

Establish a core interdisciplinary team consisting of, or similar to, the following:

Senior facility leader/administrator and/or chief nurse leader
One or two surgeons/physicians who perform medical and/or surgical procedures under sedation
One or two aNEStHESIa PrOVIDErS (anesthesiologist, CRNA)
One or two frontline perioperative nurses (e.g., preoperative/POSt-aNEStHESIa CarE UNIt nurse, circulating nurse, scrub
nurse)

If applicable to the healthcare setting, the core team might also include:

aNEStHESIa PErSONNEL (e.g., anesthesia assistant, anesthesia technician)
Other frontline perioperative staff (e.g., surgical assistant, anesthesia assistant)
Director of pharmacy or director of pharmacy operations
Staff pharmacist (from OPEratINg rOOM satellite, if applicable)
Clinical information technology specialist
Medication safety or patient safety officer/manager
Risk management and quality improvement professional

During pilot testing of the assessment, ASCs typically created teams comprising 2 to 3 practitioners, and hospitals typically
created teams comprising 3 to 8 practitioners (largely dependent on the size of the facility). Because the assessment should
be based on what actually occurs, not what is found in current policies or what should occur, the team should include frontline staff who use medications in the perioperative setting. For example, if assessing items related to MODEratE SEDatION, you
will need to include nurses, pharmacists (if applicable), aNEStHESIa PrOVIDErS, and other physicians with experience using
these medications for that purpose on the assessment team. Focusing on a systems-based approach to identifying
deficiencies, rather than blaming individuals for not following a policy, provides an opportunity for leaders in the
perioperative setting to demonstrate that they understand and practice the principles of a JUSt CULtUrE. By participating on
the team, members agree to the responsibility to evaluate, accurately and honestly, the status of perioperative medication
systems and practices in your facility.
Because medication use is a complex, interdisciplinary process, the value and accuracy of the self
assessment is significantly reduced if it is completed by a single discipline.
Choose a team leader from among the core team and a second individual to record responses. The entire team should
actively participate in the collaborative completion of the demographic questions and evaluation of the assessment items.
Set up approximately three 1.5 hour meetings for ASCs and four 1.5 hour meetings for hospitals to accomplish all tasks.
During each meeting, the team should be provided with sufficient time to complete the demographic questions or a defined
section of the self-assessment items.

2. Provide assessment items, definitions, and FaQs to all team members

Read and review the self-assessment directions, key definitions and abbreviations, the glossary, demographic questions,
assessment items, and the FAQs before beginning the assessment process. The team leader may want to provide each team
member with access to the ISMP Medication Safety Self assessment® for Perioperative Settings workbook and FAQs
for review prior to the first team meeting, which can be accessed at: www.ismp.org/node/18027.
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Instructions for Conducting the Self Assessment continued
3. Choose an option for completing the assessment

There are three options for completing the assessment.

Option 1: Use the online self-assessment form to view the demographic questions and applicable self-assessment section(s)
at team meetings. Answer each demographic question, and select your choice (A through E, or Not Applicable) for each selfassessment item, while saving your entered information between meetings. (Please see Step 1 on page 13 for information
regarding accessing the online self-assessment form and creating an account with a username and password.) Please note:
The demographic questions need to be answered and submitted to ISMP to gain access to the online assessment tool.

Option 2: Print hardcopies of the demographic questions and self-assessment items to share with team members, and
during team meetings, manually answer each demographic question and fill in your choice (A through E, or Not Applicable)
for each self-assessment item. Submission of your information to ISMP can occur at a later time using the online selfassessment form.
Option 3: Download an Excel file containing all the demographic questions and assessment items to share with team members. During team meetings, answer each demographic question, and select your choice (A through E, or Not Applicable) for
each self assessment item, while saving your entered information between meetings.

4. Collect demographic information

Before the first team meeting, the team leader may need to gather and verify some of the responses to the demographic
questions. These can be reviewed and confirmed with team members at the first meeting.

5. Convene the first team meeting to review the assessment process and answer the
demographic questions

For the first team meeting, convene the members to review the overall timeline and assessment process, become familiar
with the assessment tool, and answer the demographic questions. We anticipate that this first meeting will take approximately 1.5 hours.

6. Convene subsequent team meetings to conduct the self assessment

To conduct the assessment, convene the team, discuss each assessment item, and evaluate your facility’s success with
implementation of the item. As necessary, allow team members to investigate and verify the level of implementation of
certain items with other healthcare practitioners outside your team. When a consensus on the level of implementation for
each self-assessment item has been reached, select the appropriate choice (A through E, or Not Applicable), using the
following scoring key and guidelines:

Scoring Key
a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

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Instructions for Conducting the Self Assessment continued
Important Choice Selection guidelines

For self-assessment items with multiple components in a single item: Full implementation (choice of D or E) is
evidenced only if all components are present for some or all patients, orders, drugs, or staff. If only one or some of the
components have been partially or fully implemented for some or all patients, orders, drugs, or staff, self-assessment
choices should not exceed level C. If all components have not been fully implemented for all patients, orders, drugs, or staff,
assessment choices should not exceed level D.

For self-assessment items with multiple subparts labeled in lowercase, sequential letters (a, b, c, and so on): Select
a choice (A through E, or Not Applicable) for each of the items separately.

For self-assessment items with two or three distinct components, each separated with the word “Or,” and labeled
a and b (and c in some cases): Choose the one component within the item that is most relevant to your facility, and select
your choice (A through E, or Not Applicable) for only that one element.

For self-assessment items with an option of “Not applicable”: Select “Not Applicable” only if your facility meets the “Not
Applicable” scoring guideline for that item.

If you have questions about the assessment item, assessment process, or scoring, refer to the FAQs available on the ISMP
website: www.ismp.org/node/18027. The online self-assessment form has certain items directly linked to FAQ responses. If
you need additional assistance, contact ISMP at: [email protected], or submit a question using either the “Contact Us”
link on the ISMP website or the “Need help?” link found on the online self-assessment form.
Consider assigning an individual to record any discussion generated around each self-assessment item and the rationale
behind the selected choice. This information will not be collected and is meant for internal use only but can be very useful
to the team when reviewing scores for individual items or reassessing your organization later. Such notation will provide
insight into why a certain response was made to a self-assessment item at that point in time.

Convene the appropriate team members as long as necessary to complete the assessment as described above. The
number of meetings needed to complete the entire assessment will vary depending on the length and frequency of each
meeting, and whether team members have familiarized themselves with the tool. However, pilot testing of the tool identified an average of six 1.5-hour meetings to complete the assessment once team members are familiar with the process and
have answered the demographic questions.

7. Submit your information to ISMP

To submit your information to ISMP or to use Option 1 to complete the assessment, go to: https://ismpassessments.org/
periop/, which can also be accessed through the ISMP website at: www.ismp.org/node/18027. See the next page for further
information about creating a username and password, entering your information, submitting your completed assessment
to ISMP, and accessing your results.
Submit your self-assessment findings to ISMP by April 30, 2021.

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Instructions for Entering and Submitting Information to ISMP
1. Create a new user account for the online self-assessment form

To enter and view your assessment results, and to submit your findings to ISMP, only one individual from your facility’s core
team will need to create a free account. To create a new account, go to: https://ismpassessments.org/periop/, which can also
be accessed through the ISMP website at: www.ismp.org/node/18027, and click on the “Create new account” link. The team
member creating the account for your organization will be prompted to create a username and password, as well as to select
the one category that best describes your facility (see page 16 for the category options). There will also be an option to provide
an email address that can be used if necessary to reset your password. If your facility is part of a participating health system
or collaborative that plans to analyze its aggregate data internally, please enter your assigned health system- or collaborativespecific code (or codes if participating in more than one) in the provided field(s) under your facility’s account.
Please note: An email address is not required when setting up an account; however, because ISMP does not ask for
any information that could be used to identify a specific facility’s assessment, a user’s account and assessment results
can only be retrieved with an email address that is linked to the account (in the event of a forgotten username and/or
password), or with the account username (in the event of a forgotten password if no email address was provided).
At any point following the creation of the account, you can access your facility’s account by going to: https://ismpassess
ments.org/periop/ and entering your facility’s username and password. If you have forgotten your password, and an email
address was entered when creating the account, click on the “Lost my password” link. For retrieval of your username (if an email
address was provided) or your password (if an email address was not provided, but you have your username), please contact
ISMP. To exit the online form at any point, click on the “Log out” button found in the top right-hand corner of the webpage.
Your organization’s account will allow you to:

Enter your information into the online self-assessment form
Save your entered information and return to the online form at a later time
Submit information to ISMP
View a report of how your organization answered each general demographic question
View a report of how your organization answered the self-assessment items in each Key Element, along with your
facility’s weighted score for each item, subtotals of weighted scores for each Key Element and Core Characteristic, and
the total weighted score for the full assessment
View the Preliminary Aggregate Results workbook after the final submission date and once the results have been
tabulated near the end of the second quarter of 2021

2. Complete and submit the general demographic questions

Once a new user account has been created, access the secure online form by clicking on the “Start Assessment” button.
Based on the facility category selected when creating your account, you will be directed to the demographic questions that
are applicable to your practice setting. Complete the demographic questions and save your entered information by clicking
on the “Save” button found at the bottom of the demographics section.

If you have completed all of the demographic questions and are ready to submit, click on the “Preview before submitting”
button found at the bottom of the demographics section, which will allow you to review your responses before submitting to
ISMP. If you have not completed all of the questions, the system will alert you to those that have not yet been completed. All
demographic questions must be answered to submit your information and move to the self-assessment items.
Please note: You will not be able to access the assessment items until you have submitted your facility’s
demographic information. Once you submit your demographic information, you will not be able to change any of
your selected answers to the demographic questions.

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Instructions for Entering and Submitting Information to ISMP continued
3. Complete the self-assessment items

Once your organization has submitted its answers for the demographic questions, you will be directed to complete the selfassessment items. Follow the directions below to navigate through the online assessment and submit your responses to ISMP.

Navigation and Data Submission

To begin, click on the “Start/Resume Assessment” button. To save your organization’s answer for an assessment item and
to advance to the next item, click on the “Save and continue” button found below each self-assessment item. If you need to
end a session and resume completing the assessment at a later time, you will still need to click on the “Save and continue”
button in order to save the last item that has been answered.

Once you have answered the last item in the assessment, click on the “Save and continue button.” You will then be queried
to verify that you do want to submit your results to ISMP. Close the pop-up window and click on the “Save and continue”
button again to continue with your submission. If you are not ready to submit, you can either use the “Back” button to make
any changes or you can log out. All self-assessment items must be answered to submit your information to ISMP.
Please note: Once you submit the demographics and/or self-assessment items, you will not be able to change
any of your selected answers.

4. generate and view your reports with weighted scores

After submitting the results of the assessment to ISMP, you will automatically be directed to a report containing:

Your organization’s answer choice for each assessment item
Your organization’s numerical score and maximum weighted score for each assessment item
Your organization’s total score and the maximum possible score for each Key Element and Core Characteristic
Your organization’s total score and the maximum possible score for the entire assessment
Please note: This report can be used to later compare your facility's findings with aggregate data from other demographically similar facilities. Please keep your username and password in a secure location, as you will be able to
access your report at any time by logging into your online account.

At any point, once the self assessment has been submitted to ISMP, you can access your facility’s demographic answers and
assessment results by clicking on “My account” in the top right-hand corner of the webpage.
Weighted scores are not visible on the online self-assessment form while entering your information.
Organizations can obtain their weighted scores only after they submit their completed self assessment to
ISMP. Without weighted scores, facilities will be unable to compare their experiences to other demographically similar facilities that are participating in this study.

Explanation of Weighted Scores

To determine a weight for each self-assessment item, ISMP staff used a standard process to independently evaluate each item
to determine its impact on patient safety and its ability to sustain improvement. Weighted scores range from zero to 16 points,
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Instructions for Entering and Submitting Information to ISMP continued
depending on whether the assessment item reflects a best practice that has low-leverage (maximum value of 6 points),
medium-leverage (maximum value of 10 points), or HIgH-LEVEragE rISK-rEDUCtION StratEgIES (maximum value of 16 points).
Therefore, the self-assessment items with the highest weight are those that:

Target SyStEM DESIgN/rEDESIgN
Do not rely heavily upon human memory, performance, and vigilance
Empirically demonstrate that they are effective in reducing serious medication errors
Solve several medication-error related problems at the same time
Safeguard HIgH-rISK PatIENt populations
Prevent errors that have the greatest potential to cause patient harm
Simplify, standardize, or centralize complex, error-prone processes
Create high-level SyStEM DESIgN barriers (e.g., forcing functions, failsafes) to prevent errors
Create high-level system redundancies to capture errors before they reach patients
Reduce practitioner tolerance of risk and increase incentives for making safe behavioral choices
Make it hard for healthcare practitioners to do their job wrong, and easy for them to do it right
Develop and sustain a JUSt CULtUrE

Most of the self-assessment items are weighted in a way that results in no numerical score (zero value) unless there is partial
or full implementation (choice of C, D, or E) of the item. However, a few of the items that require extensive planning have been
assigned a weighted score for formally discussing the item (choice of B). Some of the self-assessment items are weighted in a
way that results in no numerical score unless there is full implementation of the item throughout the organization.

Weighted scores have also been assigned to “Not Applicable” choices based on the degree of risk associated with not
implementing the suggested error-reduction strategy (e.g., SMart INFUSION PUMP tECHNOLOgy implementation) or the degree
of risk avoided by not treating a specific population (e.g., pediatrics).

access to Comparative reports

ISMP will prepare and publish a Preliminary Aggregate Results workbook which will contain comparative reports of the
perioperative medication safety practices in US facilities based on the data submitted. Once the data collection period has
ended in 2021, facilities that have submitted information to ISMP will be able to access these aggregate comparative
reports by accessing their account that was used to enter and submit their self-assessment information at:
https://ismpassessments.org/periop/. This workbook should be available near the end of the second quarter of 2021. In
addition, further analysis of the data will be completed, and the results will be submitted for publication in a peer reviewed
journal.

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Demographics
All questions in the demographics section must be completed.
Please select the one category that best describes the facility completing this assessment.
Hospital that performs inpatient and/or outpatient medical and/or surgical procedures

Freestanding aSC not physically connected to a hospital, irrespective of ownership and licensure, including freestanding ASCs dedicated to specialty procedures (e.g., gastrointestinal/endoscopy procedures, interventional
radiology, ophthalmic procedures, pain management procedures, fertility procedures)
Other facility that performs outpatient medical and/or surgical procedures (please specify): _____________________

For hospitals, please complete the general Demographics for Hospitals.

For freestanding aSCs and other outpatient facilities that perform medical and/or surgical procedures, please
complete the general Demographics for Freestanding ambulatory Facilities.

General Demographics for Hospitals

about the Hospital

1) Please select the one category that best describes the number of inpatient beds currently staffed for use in
your hospital, based on the average inpatient census.

Up to 25 beds
Is your hospital a critical access hospital (CaH)? Please see the following for criteria that must be met
for a hospital to be designated as a CaH: www.ismp.org/ext/447.
Yes
No
26 to 99 beds
100 to 299 beds
300 to 499 beds
500 beds and over

2) Please select the one category that best describes the location of your hospital (based on the US Census Bureau
and Office of Management and Budget classifications).
Urban (urbanized, metropolitan area with a total population of 50,000 people or more)
Rural (micropolitan, urban cluster, or rural area with a total population of fewer than 50,000 people)

3) Please select the one category that best describes the type of organization that is responsible for establishing policy for the overall operation of your hospital.
Non-government, not-for-profit
Investor-owned, for-profit
Government, non-federal
type?
State
County

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General Demographics for Hospitals continued
City
City-county
Hospital district or authority
Other
Government, federal
type?
Military
Public Health Service (including Indian Health Service)
Veterans Affairs
Department of Justice
Other

4) Please select the one category that best describes the patient population served by your hospital.
Only pediatric and/or neonatal patients
Only adult patients
Combination of adult and pediatric and/or neonatal patients

5) Please select the one category that best describes the primary type of service (multi-specialty or specialty)
that your hospital provides to most of its patients.
Multi-specialty hospital
type of multi-specialty? (select one)
Medical and surgical procedures
Medical procedures
Surgical procedures
Specialty hospital
type of specialty? (select one)
Cardiology
Eye, ear, nose, and/or throat
Obstetrics and/or gynecology
Oncology
Orthopedics
Women and children
Other (please specify): ____________________

6) Is your hospital part of a multihospital healthcare system with two or more hospitals owned, leased,
sponsored, or managed by a central organization?
Yes
How many hospitals comprise your health system?
2 to 5
6 to 10
11 to 30
31 or more
No

7) Please indicate if your hospital is located in the US/US territory, at a US military foreign site, or in a non-US
country.
US/US territory
Please specify the state or territory in which your hospital is located. _________________________________

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General Demographics for Hospitals continued
US military foreign site
Non-US country
Please specify the non-US country in which your hospital is located. _________________________________

8) Does your hospital offer onsite training in the perioperative setting for professional students/residents/
fellows from an accredited program? FaQ
Yes
Select all that apply
Nursing students (registered nurse [RN] or licensed practical nurse [LPN] students)
Student registered nurse anesthetists
Advanced practice nursing students
Midwife students
Physician assistant students
Emergency medical technician and/or paramedic students
Pharmacy students
Pharmacy residents
Pharmacy technician students
Medical students
Medical/surgical residents/fellows
Anesthesia residents/fellows
Anesthesiologist assistant students
Surgical technician students
Radiology assistant students
Other students/residents/fellows who are involved in the perioperative MEDICatION-USE
(please specify): ________________________
No

PrOCESS

9) Is one or more part-time or full-time MEDICatION SaFEty OFFICEr (i.e., an individual dedicated to medication
safety) employed by or otherwise assigned to your hospital?
Yes
No

10) In addition to the central pharmacy, is there at least one satellite pharmacy located and operated in (or
close to) the perioperative area that prepares and dispenses medications as needed for patients?
Yes
Does at least one perioperative satellite pharmacy remain open throughout the normal hours of
operation during which the majority of scheduled (not emergent) medical and/or surgical procedures
are performed?
Yes
No
No

Medical and/or Surgical Procedures

11) Please select the one category that best describes the total number of OPEratINg rOOMS (Ors) for use in your
hospital (including Ors in all surgical suites and satellite Ors used for inpatient and outpatient procedures).
There are no OPEratINg rOOMS in our facility

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General Demographics for Hospitals continued
1 to 3
4 to 9
10 to 19
20 to 39
40 to 59
60 to 79
80 or more

12) Please select the one category that best describes the total number of
facility.

PrOCEDUrE rOOMS

for use in your

There are no PrOCEDUrE rOOMS in our facility
1 to 3
4 to 9
10 to 19
20 to 39
40 to 59
60 to 79
80 or more

13) Please select the one category that best describes the total number of medical and/or surgical procedures
(inpatient and outpatient) performed in OPEratINg rOOMS in your hospital during the year 2019. FaQ
There are no OPEratINg rOOMS in our facility
Unknown
Fewer than 1,000
1,000 to 4,999
5,000 to 9,999
10,000 to 19,999
20,000 to 29,999
30,000 to 39,999
40,000 to 49,999
50,000 or more

14) Please select the one category that best describes the total number of medical and/or surgical procedures
(inpatient and outpatient) performed outside of OPEratINg rOOMS (e.g., endoscopies and other procedures
performed in PrOCEDUrE rOOMS, radiology/nuclear medicine procedures requiring sedation) in your hospital
during the year 2019. FaQ
Unknown
Zero
1,000 to 4,999
5,000 to 9,999
10,000 to 19,999
20,000 to 29,999
30,000 to 39,999
40,000 to 49,999
50,000 or more

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General Demographics for Hospitals continued
15) Please select the types of procedures your hospital has conducted during the year 2019 (select all that apply
based on medical and/or surgical procedures performed during this timeframe). FaQ
Bariatric
Cardiothoracic/lung
Cardiovascular
Colorectal
Electroconvulsive therapy (ECT)
Endoscopy (e.g., gastrointestinal, bronchoscopy, cystoscopy)
Gastroenterology
General surgery
Gynecology
Hepatobiliary
Interventional radiology/sedating radiology and nuclear medicine procedures
Neurosurgery
Neurosurgery spine/orthopedics spine
Obstetrics
Ophthalmology
Oral/maxillofacial
Organ harvesting
Orthopedics
Otorhinolaryngology
Pain management
Plastics (cosmetic, reconstructive)/burn wound care
Podiatry foot/ankle
Transplant
Trauma/acute care surgery
Urology
Vascular

anesthesia Services

16) Please select the one category that best describes your primary staffing model for delivering
SEDatION, rEgIONaL aNEStHESIa, and/or gENEraL aNEStHESIa. FaQ

MaC, DEEP

Delivered by anesthesiologists only
Delivered by CRNAs (independently) only
Delivered by aNEStHESIa PrOVIDEr teams
Please select the one category that best describes the team composition.
Predominantly anesthesiologists
An even mix of anesthesiologists and anesthesiologist assistants (1:1 ratio)
Predominantly CRNAs
An even mix of anesthesiologists and CRNAs (1:1 ratio)
A mix of anesthesiologists, anesthesiologist assistants, and CRNAs
Delivered by NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS
Other (please specify): ____________________

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General Demographics for Hospitals continued
17) Please select your staffing model(s) for delivering MODEratE SEDatION (select all that apply). FaQ
Delivered by anesthesiologists
Delivered by CRNAs (independently)
Delivered by aNEStHESIa PrOVIDEr teams
Please select the one category that best describes the team composition.
Predominantly anesthesiologists
An even mix of anesthesiologists and anesthesiologist assistants (1:1 ratio)
Predominantly CRNAs
An even mix of anesthesiologists and CRNAs (1:1 ratio)
A mix of anesthesiologists, anesthesiologist assistants, and CRNAs
Delivered by NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS
Other (please specify): ____________________

18) Where do

MEDICatIONS

aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS obtain the
they administer to patients in the following locations (select all that apply)?

NON-CONtrOLLED

a. In OPEratINg rOOMS

There are no OPEratINg rOOMS in our facility
Non-automated shelving unit, cabinet, or drawer in the OPEratINg rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Central pharmacy deliveries/pick-ups immediately prior to or during a procedure
Perioperative satellite pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the OPEratINg rOOM
Does each OPEratINg rOOM have its own aDC?
Yes
No

b. In PrOCEDUrE rOOMS

There are no PrOCEDUrE rOOMS in our facility
Non-automated shelving unit, cabinet, or drawer in the PrOCEDUrE rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Central pharmacy deliveries/pick-ups immediately prior to or during a procedure
Perioperative satellite pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the PrOCEDUrE rOOM
Does each PrOCEDUrE rOOM have its own aDC?

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General Demographics for Hospitals continued
Yes
No

19) Where do aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS obtain the CONtrOLLED MEDICatIONS
they administer to patients in the following locations (select all that apply)?
a. In OPEratINg rOOMS

There are no OPEratINg rOOMS in our facility
Non-automated shelving unit, cabinet, or drawer in the OPEratINg rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Central pharmacy deliveries/pick-ups immediately prior to or during a procedure
Perioperative satellite pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the OPEratINg rOOM
Does each OPEratINg rOOM have its own aDC?
Yes
No

b. In PrOCEDUrE rOOMS

There are no PrOCEDUrE rOOMS in our facility
Non-automated shelving unit, cabinet, or drawer in the PrOCEDUrE rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Central pharmacy deliveries/pick-ups immediately prior to or during a procedure
Perioperative satellite pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the PrOCEDUrE rOOM
Does each PrOCEDUrE rOOM have its own aDC?
Yes
No

available technology

20) Which of the following technologies are available in perioperative areas?
a. EHrs

Yes
Where are EHrs available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS

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General Demographics for Hospitals continued

No

OPEratINg rOOMS (to document intraoperative anesthesia care)
OPEratINg rOOMS (to document intraoperative non-anesthesia care)
PrOCEDUrE rOOMS (to document intraprocedural anesthesia care)
PrOCEDUrE rOOMS (to document intraprocedural non-anesthesia care)
POSt-aNEStHESIa CarE UNItS

b. CPOE that is integrated with the EHr

Yes
Where is integrated CPOE available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

c. CPOE that is NOt integrated with the EHr

Yes
Where is non-integrated CPOE available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

d. barCODE SCaNNINg technology available for use prior to medication administration

Yes
Where is barCODE SCaNNINg technology available for use prior to medication administration?
(select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

e. SMart INFUSION PUMPS with DOSE ErrOr-rEDUCtION SyStEM (DErS) for IV medications and/or fluids

Yes
Where are SMart INFUSION PUMPS with DErS available for IV medications and/or fluids? (select all that
apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

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f. SMart INFUSION
and/or fluids

PUMPS

with

DOSE ErrOr-rEDUCtION SyStEMS

(DErS) for epidural and/or intrathecal medications

Yes
Where are SMart INFUSION PUMPS with DErS available for epidural and/or intrathecal medications
and/or fluids? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No
Select the one category that best describes your hospital.
We do not administer epidural and/or intrathecal medications and/or fluids at all
We administer epidural and/or intrathecal medications and/or fluids but do not use SMart INFUSION
PUMPS with DErS for this purpose
We only administer epidural and/or intrathecal medications manually via syringe and do not use SMart
INFUSION PUMPS with DErS for this purpose

g. END-tIDaL CarbON DIOXIDE (EtCO2) MONItOrINg (CaPNOgraPHy)

Yes
Where is END-tIDaL CarbON DIOXIDE (EtCO2) MONItOrINg (CaPNOgraPHy) available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS
PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

General Demographics for Freestanding Ambulatory Facilities

about the Facility

1) Please select the one category that best describes the average number of patient visits in the previous
month to your facility. (Visits are considered “admissions,” which are defined as completion of registration upon
entry into the ambulatory facility.)
Less than 100
100 to 499
500 to 999
1,000 to 1,499
1,500 and over

2) Please select the one category that best describes the location of your facility (based on the US Census Bureau
and Office of Management and Budget classifications).
Urban (urbanized, metropolitan area with a total population of 50,000 people or more)
Rural (micropolitan, urban cluster, or rural area with a total population of fewer than 50,000 people)

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General Demographics for Freestanding Ambulatory Facilities continued
3) Please select the one category that best describes the type of organization that is responsible for establishing policy for the overall operation of your facility.
Investor-owned, for-profit
type?
Physician ownership
Corporate ownership
Hospital ownership
Combination (e.g., physician/hospital, physician/corporate)
Non-government, not-for-profit
type?
Physician ownership
Corporate ownership
Hospital ownership
Combination (e.g., physician/hospital, physician/corporate)
Government, non-federal
type?
State
County
City
City-county
Other
Government, federal
type?
Military
Public Health Service (including Indian Health Service)
Veterans Affairs
Department of Justice
Other

4) Please select the one category that best describes the patient population served by your facility.
Only pediatric patients
Only adult patients
Combination of adult and pediatric patients

5) Is your facility part of a larger healthcare system with two or more healthcare facilities owned, leased,
sponsored, or managed by a central organization?
Yes
How many facilities comprise your health system?
2 to 5
6 to 10
11 to 30
31 or more
No

6) Please indicate if your facility is located in the US/US territory, at a US military foreign site, or in a non-US
country.
US/US territory
Please specify the state or territory in which your facility is located. ________________________________

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General Demographics for Freestanding Ambulatory Facilities continued
US military foreign site
Non-US country
Please specify the non-US country in which your facility is located. _________________________________

7) Does your facility offer onsite training in the perioperative setting for professional students/residents/
fellows from an accredited program? FaQ
Yes
Select all that apply
Nursing students (registered nurse [RN] or licensed practical nurse [LPN] students)
Student registered nurse anesthetists
Advanced practice nursing students
Midwife students
Physician assistant students
Emergency medical technician and/or paramedic students
Pharmacy students
Pharmacy residents
Pharmacy technician students
Medical students
Medical/surgical residents/fellows
Anesthesia residents/fellows
Anesthesiologist assistant students
Surgical technician students
Radiology assistant students
Other students/residents/fellows who are involved in the perioperative MEDICatION-USE
(please specify): ________________________
No

PrOCESS

8) Is one or more part-time or full-time MEDICatION SaFEty OFFICEr (i.e., an individual dedicated to medication
safety) employed by or otherwise assigned to your facility?
Yes
No

9) How are medications/solutions provided to your facility? (select all that apply)

Through an onsite pharmacy within the facility
Through an offsite pharmacy that is part of the same health system
Through an offsite pharmacy that is owned and governed separately from the facility
Through a wholesaler that ships ordered medications/solutions directly to the facility
Through the aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS who bring their own
medications obtained from outside of the facility

10) Is a licensed pharmacist physically present onsite during all hours of operation?

Yes
No
Select the one category that best describes your facility.
A pharmacist is onsite for some, but not all, hours of operation (e.g., some hours daily, weekly, or monthly)
A pharmacist is never onsite during the hours of operation

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General Demographics for Freestanding Ambulatory Facilities continued
Medical and/or Surgical Procedures

11) Please select the one category that best describes the total number of OPEratINg rOOMS in your facility.
There are no OPEratINg rOOMS in our facility
1 to 3
4 to 9
10 to 19
20 to 29
30 or more

12) Please select the one category that best describes the total number of
facility.

PrOCEDUrE rOOMS

for use in your

There are no PrOCEDUrE rOOMS in our facility
1 to 3
4 to 9
10 to 19
20 to 29
30 or more

13) Please select the one category that best describes the total number of medical and/or surgical procedures
performed in your facility during the year 2019. FaQ
Unknown
Fewer than 1,000
1,000 to 4,999
5,000 to 9,999
10,000 to 19,999
20,000 to 29,999
30,000 to 39,999
40,000 to 49,999
50,000 or more

14) Please select the types of procedures your facility has conducted during the year 2019 (select all that apply
based on medical and/or surgical procedures performed during this timeframe). FaQ
Bariatric
Cardiothoracic/lung
Cardiovascular
Colorectal
Dental
Electroconvulsive therapy (ECT)
Endoscopy (e.g., gastrointestinal, bronchoscopy, cystoscopy)
Gastroenterology
General surgery
Gynecology/fertility
Hepatobiliary
Interventional radiology/sedating radiology and nuclear medicine procedures
Neurosurgery
Neurosurgery spine/orthopedics spine

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General Demographics for Freestanding Ambulatory Facilities continued
Obstetrics
Ophthalmology
Oral/maxillofacial
Orthopedics
Otorhinolaryngology
Pain management
Plastics (cosmetic, reconstructive)/burn wound care
Podiatry foot/ankle
Urology
Vascular

anesthesia Services

15) Please select the one category that best describes your primary staffing model for delivering
SEDatION, rEgIONaL aNEStHESIa, and/or gENEraL aNEStHESIa. FaQ

MaC, DEEP

We do not deliver MaC, DEEP SEDatION, rEgIONaL aNEStHESIa, and/or gENEraL aNEStHESIa
Delivered by anesthesiologists only
Delivered by CRNAs (independently) only
Delivered by aNEStHESIa PrOVIDEr teams
Please select the one category that best describes the team composition.
Predominantly anesthesiologists
An even mix of anesthesiologists and anesthesiologist assistants (1:1 ratio)
Predominantly CRNAs
An even mix of anesthesiologists and CRNAs (1:1 ratio)
A mix of anesthesiologists, anesthesiologist assistants, and CRNAs
Delivered by NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS
Other (please specify): ____________________

16) Please select your staffing model(s) for delivering MODEratE SEDatION (select all that apply). FaQ
Delivered by anesthesiologists
Delivered by CRNAs (independently)
Delivered by aNEStHESIa PrOVIDEr teams
Please select the one category that best describes the team composition.
Predominantly anesthesiologists
An even mix of anesthesiologists and anesthesiologist assistants (1:1 ratio)
Predominantly CRNAs
An even mix of anesthesiologists and CRNAs (1:1 ratio)
A mix of anesthesiologists, anesthesiologist assistants, and CRNAs
Delivered by NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS
Other (please specify): ____________________

17) Where do

MEDICatIONS

aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS obtain the NON-CONtrOLLED
they administer to patients in OPEratINg rOOMS and/or PrOCEDUrE rOOMS? (select all that apply)

Non-automated shelving unit, cabinet, or drawer in the OPEratINg rOOM and/or PrOCEDUrE rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)

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General Demographics for Freestanding Ambulatory Facilities continued
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Internal pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the OPEratINg rOOM and/or PrOCEDUrE rOOM
Does each OPEratINg rOOM and/or PrOCEDUrE rOOM have its own aDC?
Yes
No

18) Where do aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS obtain the CONtrOLLED MEDICatIONS
they administer to patients in OPEratINg rOOMS and/or PrOCEDUrE rOOMS? (select all that apply)

Non-automated shelving unit, cabinet, or drawer in the OPEratINg rOOM and/or PrOCEDUrE rOOM
Anesthesia workroom/supply area
Anesthesia kit, tray, or cart stocked or prepared by pharmacy (used independently of an ADC)
Anesthesia kit, tray, or cart stocked or prepared by aNEStHESIa PErSONNEL (used independently of an ADC)
Dedicated anesthesia refrigerator
Refrigerator used by multiple disciplines (e.g., nurses, aNEStHESIa PrOVIDErS)
Internal pharmacy deliveries/pick-ups immediately prior to or during a procedure
aNEStHESIa PrOVIDErS and/or NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS bring their own medications obtained
from outside of the facility
ADC(s) located in a SEMI-rEStrICtED arEa(S)
ADC(s) located in the OPEratINg rOOM and/or PrOCEDUrE rOOM
Does each OPEratINg rOOM and/or PrOCEDUrE rOOM have its own aDC?
Yes
No

available technology

19) Which of the following technologies are available in perioperative areas?
a. EHr

Yes
Where are EHrs available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS (to document intraoperative/intraprocedural anesthesia care)
OPEratINg rOOMS and/or PrOCEDUrE rOOMS (to document intraoperative/intraprocedural non-anesthesia
care)
POSt-aNEStHESIa CarE UNItS
No

b. CPOE that is integrated with the EHr

Yes
Where is integrated CPOE available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

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General Demographics for Freestanding Ambulatory Facilities continued
c. CPOE that is NOt integrated with the EHr

Yes
Where is non-integrated CPOE available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

d. barCODE SCaNNINg technology available for use prior to medication administration

Yes
Where is barCODE SCaNNINg technology available for use prior to medication administration? (select
all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

e. SMart INFUSION PUMPS with DOSE ErrOr-rEDUCtION SyStEMS (DErS) for IV medications and fluids

Yes
Where are SMart INFUSION PUMPS with DErS available for IV medications and fluids? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

f. SMart INFUSION PUMPS with DOSE ErrOr-rEDUCtION SyStEM (DErS) for epidural and/or intrathecal medications and/or
fluids

Yes
Where are SMart INFUSION PUMPS with DErS available for epidural and/or intrathecal medications
and/or fluids? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No
Select the one category that best describes your facility.
We do not administer epidural and/or intrathecal medications and/or fluids at all
We administer epidural and/or intrathecal medications and/or fluids but do not use SMart INFUSION
PUMPS with DErS for this purpose
We only administer epidural and/or intrathecal medications manually via syringe and do not use SMart
INFUSION PUMPS with DErS for this purpose

g. END-tIDaL CarbON DIOXIDE (EtCO2) MONItOrINg (CaPNOgraPHy)

Yes
Where is END-tIDaL CarbON DIOXIDE (EtCO2) MONItOrINg (CaPNOgraPHy) available? (select all that apply)
PrEOPEratIVE HOLDINg arEaS
OPEratINg rOOMS and/or PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNItS
No

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Self-Assessment Items

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

Key Element I: Patient Information

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Core Characteristic # 1

a

b

C

D

E

Essential patient information is obtained, readily available in useful form, and considered when prescribing, dispensing,
and administering perioperative medications, and when monitoring the effects of these medications.

1
2

3

FaQ

4

5

FaQ

6
7

A computer-generated identification bracelet is verified for correctness using two
unique patient identifiers and placed on the patient prior to medication administration and/or the medical and/or surgical procedure.

A complete (home) medication list, including each prescription and over-thecounter medication’s name, purpose, dose, frequency, route of administration,
and time last taken, is collected and/or verified with patients before they
undergo a medical and/or surgical procedure; and the medication list is
documented in a single, standard location in the EHR or medical record.

Practitioners collecting each patient’s preoperative or preprocedure (home) medication list use regularly updated, scripted questions or prompts to help identify
all medications and substances that may not be readily identified by patients,
including: vitamins, herbal products (including teas), topical products, otic and
ophthalmic medications, immunosuppressants, patches, inhalers, depot
injections, drug-eluting implantable devices, vaping products, cannabis, illicit
drugs, and alcohol and tobacco use.

Medications taken at home by the patient before the medical and/or surgical
procedure are reconciled with the list of medications prescribed at the time of
admission/encounter, upon transfer within the facility (e.g., from the POStaNEStHESIa CarE UNIt to an inpatient unit), and upon discharge after outpatient
surgery; and any identified discrepancies (e.g., omissions, duplications,
contraindications, unclear information) are resolved.

Adverse drug reactions distinguished as either allergies or DrUg INtOLEraNCES,
along with the specific reactions (if known) to each, are collected and/or verified
with each patient before the medical and/or surgical procedure, and are listed in
a standardized, clearly visible location on all drug-related pages or screens of the
EHR or medical record, preoperative or preprocedure checklists, anesthesia
record, and order screens/forms.
All patient allergy information entered into the EHR or medical record is properly
coded to allow for clinical decision support allergy screening.

Scoring guideline: Do not score higher than B if allergy information is not entered into
an EHR, or if allergy information is entered into an EHR but clinical decision support
(electronic allergy screening) does not occur.

Information related to patient allergies, DrUg INtOLEraNCES, and specific reactions
(if known) is readily visible (e.g., in the EHR, on OPEratINg rOOM whiteboards) to all
practitioners during the medical and/or surgical procedure.

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a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element I: Patient Information (continued)

8

FaQ

9

10

FaQ

11
12
13

14

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

If an adverse drug reaction (e.g., DrUg INtOLEraNCE, allergic reaction) or specific
challenge (e.g., difficult intubation) occurs during a medical and/or surgical
procedure, the patient and/or caregiver is informed about the reaction and/or
challenge, and educated about the importance of sharing this information with
their healthcare providers.

a

b

C

D

E

A standard process based on established definitions is used to determine if an
adult patient is OPIOID-NaïVE or OPIOID-tOLEraNt and whether the patient is a HIgHrISK PatIENt for respiratory depression; and this information is documented in a
designated location in the EHR or medical record and used to establish a therapeutic and monitoring plan for patients undergoing a medical and/or surgical
procedure.

Scoring guideline: Choose Not Applicable only if adult patients never undergo medical
and/or surgical procedures in your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if pediatric patients never undergo
medical and/or surgical procedures in your facility.

NOT APPLICABLE

A standard process based on an established definition is used to determine if a
pediatric patient is a HIgH-rISK PatIENt for respiratory depression; and this information is documented in a designated location in the EHR or medical record and
used to establish a therapeutic and monitoring plan for patients undergoing a
medical and/or surgical procedure.

On the day of the procedure, patient weights measured only in metric units
(i.e., grams or kilograms) are obtained for all patients undergoing a medical
and/or surgical procedure.

Exception: Stated, estimated, or historical weights are only acceptable in emergencies.

Computer information system screens, MEDICatION DELIVEry DEVICE screens
(e.g., SMart INFUSION PUMPS), printouts, and preprinted order forms prompt for and
display the patient’s weight in metric units only.

Patient selection criteria are followed for PCA and/or PCEA therapy, which exclude
patients who cannot control medication delivery themselves due to their level of
consciousness, physiological condition, or limited cognitive ability and comprehension.

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

Before administering local anesthetics, patients are screened to identify an
increased risk of local anesthetic systemic toxicity (e.g., infants less than 6 months
old, small patient size, advanced age, cardiac conditions, metabolic disease, liver
disease, acidosis, medications that inhibit sodium channels [e.g., lidocaine,
flecainide, bretylium, phenytoin, procainamide]); and any identified increase in
toxicity risk is considered when planning local anesthetic use.

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NOT APPLICABLE

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33

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element I: Patient Information (continued)

FaQ

15

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

For patients with type 1 or type 2 diabetes mellitus, blood glucose is monitored at
least once within 4 hours before a medical and/or surgical procedure, at least
once during a procedure that lasts 2 hours or more, and at least once within 2
hours after the procedure.

16

Continuous electronic monitoring of both oxygenation (e.g., pulse oximetry) and
adequacy of ventilation (e.g., END-tIDaL CarbON DIOXIDE [EtCO2] MONItOrINg
[CaPNOgraPHy]) is required during a medical and/or surgical procedure for patients
who are receiving MODEratE SEDatION, DEEP SEDatION, MaC, rEgIONaL aNEStHESIa (with
a local anesthetic and an opioid), and/or gENEraL aNEStHESIa.

17

Continuous electronic monitoring of both oxygenation (e.g., pulse oximetry) and
adequacy of ventilation (e.g., END-tIDaL CarbON DIOXIDE [EtCO2] MONItOrINg
[CaPNOgraPHy]) is required postoperatively or postprocedurally for patients who
have received MODEratE SEDatION, DEEP SEDatION, MaC, rEgIONaL aNEStHESIa (with a
local anesthetic and an opioid), and/or gENEraL aNEStHESIa until facility-defined
parameters for recovery have been reached.

FaQ

18

19

a

b

C

D

E

Scoring guideline: Do not score higher than C if patients are only monitored for
oxygenation (e.g., pulse oximetry) or adequacy of ventilation (e.g., END-TIDAL CARBON
DIOXIDE [ETCO2] MONITORING [CAPNOGRAPHY]), rather than both.

Scoring guideline: Do not score higher than C if patients are only monitored for
oxygenation (e.g., pulse oximetry) or adequacy of ventilation (e.g., END-TIDAL CARBON
DIOXIDE [ETCO2] MONITORING [CAPNOGRAPHY]), rather than both.

Continuous electronic monitoring of both oxygenation (e.g., pulse oximetry) and
adequacy of ventilation (e.g., END-tIDaL CarbON DIOXIDE [EtCO2] MONItOrINg
[CaPNOgraPHy]) is required for patients in the perioperative setting who are receiving
continuous or intermittent IV or neuraxial opioids (including PCA or PCEA).

Scoring guideline: Do not score higher than C if patients are only monitored for
oxygenation (e.g., pulse oximetry) or adequacy of ventilation (e.g., END-TIDAL CARBON
DIOXIDE [ETCO2] MONITORING [CAPNOGRAPHY]), rather than both. Choose Not Applicable only
if patients never receive IV or neuraxial opioids in your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if patients never receive IV or
neuraxial opioids in your facility.

NOT APPLICABLE

Postoperative and postprocedural patients receiving continuous or intermittent
IV or neuraxial opioids (including PCA or PCEA) are monitored at facility-defined
frequencies for the following: level of sedation using a sedation scale; pain score;
and vital signs (including rate, depth, and quality of respirations).

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a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element I: Patient Information (continued)

20

21

22
23
24

25

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Continuous electronic monitoring of both oxygenation (e.g., pulse oximetry) and
adequacy of ventilation (e.g., END-tIDaL CarbON DIOXIDE [EtCO2] MONItOrINg
[CaPNOgraPHy]) is required for patients in the perioperative setting who are
receiving rEgIONaL aNEStHESIa (e.g., interscalene block) with a local anesthetic and
an opioid.

a

b

C

D

Scoring guideline: Do not score higher than C if patients are only monitored for
oxygenation (e.g., pulse oximetry) or adequacy of ventilation (e.g., END-TIDAL CARBON
DIOXIDE [ETCO2] MONITORING [CAPNOGRAPHY]), rather than both. Choose Not Applicable
only if patients never receive REGIONAL ANESTHESIA with a local anesthetic and an opioid
in your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if patients never receive
ANESTHESIA with a local anesthetic and an opioid in your facility.

NOT APPLICABLE

Postoperative and postprocedural patients receiving rEgIONaL aNEStHESIa
(e.g., interscalene block) with a local anesthetic and an opioid are monitored at
facility-defined frequencies for the following: level of sedation using a sedation
scale; mental and neurological status; pain score; degree of motor or sensory
block (if applicable); and vital signs (including rate, depth, and quality of
respirations).
REGIONAL

Patients who receive a local anesthetic into a body part (e.g., knee, elbow,
shoulder, gums) involved in a medical and/or surgical procedure are monitored
for at least 30 minutes after injection for signs of an adverse reaction, even when
the local anesthetic dose is small; atypically administered (e.g., subcutaneous,
mucosal, topical); administered by a surgeon, podiatrist, or dentist; or after recent
tourniquet deflation.

E

After a medical and/or surgical procedure, patients who have received MODEratE
SEDatION, DEEP SEDatION, MaC, rEgIONaL aNEStHESIa with an opioid, and/or gENEraL
aNEStHESIa are monitored in a recovery area staffed with practitioners who are
trained to monitor and recover sedated patients.

Predefined criteria for adults (e.g., Aldrete Scoring System, Post-Anesthetic
Discharge Scoring System), and for neonates and/or pediatric patients if applicable (e.g., ability to remain awake for at least 20 minutes in a quiet environment),
are used to determine when a patient has approached a pre-sedation state and
can be discharged from the facility or no longer requires postprocedural recovery
monitoring.
A longer period of monitoring beyond meeting predefined criteria (see item # 24)
is required for patients who have received a long-acting sedative, a reversal agent
in the POSt-aNEStHESIa CarE UNIt and/or other recovery area, and/or have an
anatomical airway problem or underlying medical condition that might compromise blood pressure or ventilation (e.g., sleep-disordered breathing), or if the
ability of the responsible adult to observe the patient after discharge is limited.

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a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element II: Drug Information

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Core Characteristic # 2

a

b

C

D

E

Essential drug information is readily available in useful form and considered when prescribing, dispensing, and
administering perioperative medications, and when monitoring the effects of these medications.

26

27
28
29
30

31

Medication-related reference materials (e.g., commercially available and facilityprepared charts, guidelines, protocols, policies) used in the perioperative setting
are approved by an appropriate interdisciplinary committee (e.g., pharmacy and
therapeutics); do not include ErrOr-PrONE abbrEVIatIONS, including drug name
abbreviations (e.g., AT II, AT III, epi); and medication-related reference materials
are updated at least annually (commercially available materials are updated
when the next edition/version becomes available).
Equianalgesic dosing guidance for converting to and from oral, parenteral, and
transdermal opioids has been reviewed and approved by a pain management
specialist and/or an interdisciplinary committee (e.g., pharmacy and therapeutics); and the guidance is easily accessible to all practitioners when prescribing,
dispensing/selecting, and administering perioperative opioids.
Cumulative doses of organization-defined analgesics with safe MaXIMUM DOSE
limits that should not be exceeded (e.g., daily acetaminophen limit, ketorolac
5 day limit) are tracked and visible to all practitioners when prescribing, verifying,
dispensing/selecting, and administering medications, including doses administered intraoperatively.

When same-day surgery patients are discharged with prescriptions or instructions to continue taking organization-defined analgesics limited by safe cumulative doses, prescriptions and instructions reflect the prescriber’s awareness of
doses administered prior to discharge, and patients are warned to not exceed
safe limits.

Safe dosage ranges, including MaXIMUM DOSES, have been established and are
followed for local anesthetics and take into consideration patient-related
factors such as age and organ dysfunction (e.g., renal impairment, liver impairment), which may influence the effect and the pharmacokinetics of the local
anesthetic.

Safe dosage ranges, including MaXIMUM DOSES, have been established and are
followed for perioperative IV push doses and/or infusions of high-alert medications
such as morphine, heparin, insulin, vasopressors, and neuromuscular blocking
agents, and take into consideration patient-related factors such as age and organ
dysfunction (e.g., renal impairment, liver impairment), which may influence the
effect and the pharmacokinetics of the medications.

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a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element II: Drug Information (continued)

32

33
34

35

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Safe dosage ranges, including MaXIMUM DOSES, have been established and are
followed for NEUraXIaL aNEStHESIa and/or epidural injections, and take into consideration patient-related factors such as age and organ dysfunction (e.g., renal
impairment, liver impairment), which may influence the effect and the pharmacokinetics of the medications.

Scoring guideline: Choose Not Applicable only if patients never receive
ANESTHESIA and/or epidural injections.

NEURAXIAL

Standard policies, protocols, guidelines, and/or order sets have been established
and are followed for postprocedural and/or postoperative IV solutions used to
hydrate patients (adult, pediatric, and/or neonatal patients, as applicable) that
acknowledge the importance of maintenance solutions with sodium chloride to
prevent hyponatremia.

37

b

C

D

E

NOT APPLICABLE

Standard policies, protocols, guidelines, and/or order sets have been established
and are followed to identify, treat, and monitor patients (adult, pediatric, and/or
neonatal patients, as applicable) with signs of hyponatremia, water intoxication,
and/or syndrome of inappropriate antidiuretic hormone (SIADH).

Preoperative and postoperative orders for medications (including hydrating solutions) are entered into a CPOE system (or pharmacy computer system) and
screened electronically against the patient’s current medications and medical
profile to identify potential allergies, contraindications, interactions, duplicate
therapy, and appropriateness of doses before medications are administered,
unless a delay in administration could result in patient harm.

Scoring guideline: Do not score higher than B if orders are not entered into a
system or pharmacy computer system.

36

a

CPOE

Preoperative and postoperative orders for medications (including hydrating solutions) are verified by a pharmacist (remotely or onsite) before medications are
administered, unless a delay in administration could result in patient harm.

Scoring guideline: Do not score higher than B if a pharmacist is not available to
verify orders before medication administration.

Standardized, organization-approved emergency drug dosing guidelines (including weight-based resources for pediatric and neonatal patients, if applicable) are
available as a hardcopy on adult, pediatric, and/or neonatal code carts, or immediately accessible in an electronic form; and the information provided corresponds to the dosage forms and concentrations of drugs available in the code
carts.
Scoring guideline: If your facility provides care to only adults, neonates, or pediatric
patients, score this item as it relates to the patient population you serve.

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37

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element II: Drug Information (continued)

38
39
40
41
42
43

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

A protocol for treating malignant hyperthermia is readily accessible, along with
current reference material from the Malignant Hyperthermia Association of the
United States (MHAUS) and the MHAUS hotline (phone number).

a

b

C

D

E

A standard process is in place for screening patients for recent aNtItHrOMbOtIC
MEDICatION use before medical and/or surgical procedures; and if therapy must be
discontinued, protocols or guidelines define when these medications should be
stopped and restarted, and when alternative agents to bridge the patient should
be considered.
If an aNtItHrOMbOtIC MEDICatION(S) is held for a medical and/or surgical procedure
and if the procedure is then postponed, a process is in place to remind the prescriber to evaluate the need to resume antithrombotic therapy.

A perioperative glycemic management plan is in place and followed to manage
oral hypoglycemic medications and insulin in patients with prediabetes or type 1
or type 2 diabetes mellitus preoperatively (while NPO) and postoperatively to
reduce the likelihood of hyperglycemia or hypoglycemia.
Practitioner- and/or procedure-specific preference cards provide clear and
concise medication instructions in an electronic format (not handwritten), and
are approved and/or updated annually by an interdisciplinary committee
(e.g., pharmacy and therapeutics).

The medication information contained in practitioner- and/or procedure-specific
preference cards is communicated in a standardized format (e.g., medication
name, concentration/strength, intended route, anticipated quantity, special
handling instructions for high-alert medications and/or HazarDOUS DrUgS); and the
preference cards do not contain ErrOr-PrONE abbrEVIatIONS, including drug name
abbreviations.

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a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element III: Communication of Drug Orders and Other Drug Information
a

Core Characteristic # 3

b

C

D

E

Methods of communicating drug orders and other drug information in the perioperative setting are streamlined,
standardized, and automated to minimize the risk for error.

44
45
46
47

48
49
50
FaQ

51

In the perioperative setting (including during rEgIONaL aNEStHESIa initiated prior to
a procedure), the practitioner providing a medication or solution to the surgeon,
surgical technician, or aNEStHESIa PrOVIDEr, or placing a medication or solution on
the sterile field (e.g., topical thrombin), states what is being provided (e.g., drug
name, concentration, expiration date); and the recipient repeats back the information for verification.

Intraoperatively (including during emergencies), when a surgeon asks an
aNEStHESIa PrOVIDEr to administer drug therapy (e.g., heparin, protamine,
oxytocin), the aNEStHESIa PrOVIDEr communicates the drug therapy administration
to the rest of the team (e.g., drug name, dose if important).

Intraoperatively (including during emergencies), drug therapy (e.g., vasopressors,
chemotherapy, methylene blue) administered by practitioners within the sterile
field is communicated to the aNEStHESIa PrOVIDEr and to the rest of the team
(e.g., drug name, dose if important).

During a medical and/or surgical procedure, when care is transferred (e.g., shift
change, break) between aNEStHESIa PrOVIDErS, the arriving aNEStHESIa PrOVIDEr
confirms with the leaving aNEStHESIa PrOVIDEr the names, concentrations, labels,
and remaining volumes of any medication or solution currently infusing and/or
pulled/prepared for use to deliver the planned anesthesia.

During a medical and/or surgical procedure, when care is transferred (e.g., shift
change, break) between perioperative nurses or any other participating
practitioner working within the sterile field, the arriving practitioner reviews the
medications available on the back table or on the sterile field, and the amount
and time that each medication was administered, with the practitioner(s) who is
leaving the OPEratINg rOOM or PrOCEDUrE rOOM.

Face-to-face verbal orders from prescribers who are onsite in the facility are
never accepted, except in emergencies or during sterile procedures where
ungloving would be impractical.

During a medical and/or surgical procedure, a medication order communicated
verbally by the prescriber is read back (or repeated back under sterile conditions)
to the prescriber, stating doses digit-by-digit (e.g., “one-five” instead of “15”) for
verification before administration; and the verbal order is documented in the EHR
or medical record.
Standard order sets for pre- and postoperative care have been developed
through group consensus, approved by an appropriate interdisciplinary committee (e.g., pharmacy and therapeutics), and are used to manage perioperative
patients.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 39

39

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element III: Communication of Drug Orders and Other Drug Information (continued)

52
53
FaQ

a

b

PCA (and PCEA if used) is initially prescribed using a standard order set.

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

Order sets for PCA (and PCEA if used) have been established and are followed,
which include:

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

Recommended initial and MaXIMUM DOSES (bOLUS DOSES and demand doses) and a
lockout interval based on whether the patient is OPIOID-NaïVE or OPIOID-tOLEraNt
(adults), and/or a HIgH-rISK PatIENt for respiratory depression (adults and/or older
pediatric patients)
Detection and management of inadequate analgesia

c

Monitoring guidelines

d

Sedation scores that indicate a need to increase the frequency of patient monitoring, adjust the PCA (or PCEA) dose, stop the PCA (or PCEA), call the prescriber,
provide airway support and/or oxygen, and/or administer naloxone

e

An order for naloxone to reverse respiratory depression, including directions for
use
Order sets for PCA and/or PCEA are initiated before leaving the POSt-aNEStHESIa
and implemented before the patient has been transferred to an inpatient clinical unit.

a

b

C

D

E

NOT APPLICABLE
Score Each Item
Individually

NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE

CarE UNIt

54

Exception: The PCA or PCEA is specifically ordered to start in the inpatient unit or is
clearly contraindicated due to patient safety concerns in the perioperative setting.

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

55

Standard protocols, guidelines, and/or order sets have been established and are
followed for the management of patients who receive an IV or neuraxial opioid
postoperatively for pain management (excluding PCA and/or PCEA), which
includes:

Scoring guideline: Choose Not Applicable only if patients never receive an IV or
neuraxial opioid analgesic in your facility.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

Score Each Item
Individually

continued on page 40

40

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element III: Communication of Drug Orders and Other Drug Information (continued)

a
b
c
d
e
56
a
b
c

The use of specific opioids, including dosing guidelines that differentiate between
the management of OPIOID-NaïVE, OPIOID-tOLEraNt, and/or HIgH-rISK PatIENtS; and
conditions that require dose adjustments
Detection and management of inadequate analgesia
Monitoring requirements, including the frequency, intensity, duration, and
methods of monitoring based on patients’ individual risk factors, response to
therapy, and pharmacologic regimen

Identification and management of potentially serious adverse effects such as
respiratory depression, inadequate oxygenation/ventilation, unintended advancing sedation, and allergic reaction
An order for naloxone to reverse respiratory depression, including directions for
use

Standard protocols, guidelines, and/or order sets have been established and are
followed for the management of patients who receive NEUraXIaL aNEStHESIa, which
include:
Scoring guideline: Choose Not Applicable only if
provided in your facility.

NEURAXIAL ANESTHESIA

is never

Detection and management of inadequate analgesia
Monitoring requirements, including the frequency, intensity, duration, and
methods of monitoring based on patients’ individual risk factors, response to
therapy, and pharmacologic regimen

Identification and management of potentially serious adverse effects such as
respiratory depression, accidental catheter disconnection, opioid/local anesthetic systemic toxicity, and allergic reaction

d

When to monitor, discontinue, and restart aNtItHrOMbOtIC MEDICatIONS (to prevent
spinal hematoma)

57

Order sets have been established and are used for ELaStOMErIC PUMPS, which
include the indication for use; the medication, concentration, dose, infusion rate,
and route of administration; concomitant analgesics (if acceptable); and patient
monitoring requirements.
Scoring guideline: Choose Not Applicable only if ELASTOMERIC PUMPS are never used in
the perioperative setting in your facility.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

a

b

C

D

E

NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
Score Each Item
Individually

NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE

NOT APPLICABLE

continued on page 41

41

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element III: Communication of Drug Orders and Other Drug Information (continued)

58

59

60

61

62
63
64

When patients are transferred from the OPEratINg rOOM or PrOCEDUrE rOOM to a POStaNEStHESIa CarE UNIt or recovery area, the aNEStHESIa PrOVIDEr or NON-aNEStHESIOLOgISt
SEDatION PraCtItIONEr immediately communicates a verbal HaND-OFF report covering
the procedure and any complications, allergy information, anesthesia and other
medications/parenteral fluids administered, patient assessment (e.g., vital signs,
estimated blood loss), any implanted devices, tubes, or pumps, the plan for pain
control, and any other relevant medication-related information; and the aNEStHESIa
PrOVIDEr or NON-aNEStHESIOLOgISt SEDatION PraCtItIONEr supplies associated documentation to the practitioner(s) accepting care of the patient for recovery.

a

b

C

D

E

After a medical and/or surgical procedure, if a patient is being transferred to an
external healthcare provider (e.g., long-term care, rehabilitation, assisted living), a
perioperative practitioner provides a verbal HaND-OFF via phone to a practitioner
at the transferring facility (in addition to providing a written transfer/referral
form) prior to the transfer.

After a medical and/or surgical procedure, if a patient is being transferred to an
external healthcare provider (e.g., long-term care, rehabilitation, assisted living), a
perioperative practitioner prepares a written standard transfer/referral form,
conducts medication reconciliation, and verifies the accuracy of the medication
information provided, specifying which medications are being discontinued, the
reason for discontinuation, and any new medications or changes to previous
medications that the patient was taking prior to the procedure, including the time
of the last dose administered.

A standard communication mechanism is in place to notify perioperative practitioners (e.g., aNEStHESIa PrOVIDErS, surgeons, nurses) when a potential or actual
drug shortage or withdrawal from the market could impact their practice; and
practitioners are educated about rationing drugs in short supply (e.g., use with
priority patients) and/or available alternative products/concentrations and how
to use them safely, including warnings about potential adverse events, prior to
their availability.

Systems are in place to deter and promptly identify drug diversion at any point of
the MEDICatION-USE PrOCESS, from procurement to administration and/or wasting of
unused drug; and an internal group is available to quickly investigate concerns
that arise during drug diversion surveillance.

Perioperative leaders and managers promote interdisciplinary respect and cooperation, actively engage in dialogue about the untoward consequences of intimidation, and deal effectively with reported and observed disruptive behaviors to
lessen the hierarchal structures that make it difficult or uncomfortable for people,
regardless of education, experience, or rank, to raise concerns.
A defined, clear, and effective process is followed to resolve conflicts when there
is concern or disagreement about the safety of a medication order or practice
that may place a patient at risk; and practitioners are aware of this process.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 42

42

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element IV: Drug Labeling, Packaging, and Nomenclature
a

Core Characteristic # 4

b

C

D

E

Strategies are undertaken to minimize the possibility of perioperative errors with pharmacy-prepared, COMMERCIALLY
MANUFACTURED, and/or COMMERCIALLY PREPARED drug products that have similar or confusing labeling/packaging and/or
drug names that look and/or sound alike.
FaQ

65
66
67
68
69
70

71

72

An interdisciplinary group of perioperative practitioners examines the labeling
and packaging of medications (pharmacy-prepared, COMMErCIaLLy MaNUFaCtUrED,
COMMErCIaLLy PrEParED) being considered for use in the perioperative setting to
identify error potential before use.

Medications that have similar or confusing labels, packaging, and/or drug names
are stored separately in individual compartments in anesthesia trays/kits/carts
and/or ADCs (e.g., locked, lidded compartments).

Auxiliary warnings and/or other label enhancements (e.g., taLL MaN LEttErINg to
accentuate differences in look-alike drug name pairs) are used on packages
and/or storage compartments of perioperative medications with look-alike or
error-prone names, packages, and/or labels.
EPINEPHrine-containing local anesthetics (e.g., lidocaine 1% with EPINEPHrine
1:100,000) are stored separately from plain local anesthetic formulations (e.g., lidocaine 1%) in all perioperative storage areas, including trays, kits, carts, and/or ADCs.

Irrigation solutions are not placed on the same pole as an IV infusion; and a warning label stating, “For Irrigation Use Only,” is included on the irrigation solution
container.

Medication storage in medication trays, kits, carts, and/or ADCs in the perioperative setting is configured to allow practitioners to immediately view the label
while selecting medications (i.e., label is facing up), instead of a “cap up” storage
configuration which has only the top of the vial facing up.

Vials of tranexamic acid stocked in ADCs and anesthesia trays, kits, carts, drawers,
or other anesthesia storage areas are sequestered or separated from look-alike
vials used for rEgIONaL aNEStHESIa (e.g., bupivacaine, ropivacaine).

Scoring guideline: Choose Not Applicable only if tranexamic acid vials are never
stocked in your facility (e.g., tranexamic acid is never used for patients, or vials have
been fully replaced by COMMERCIALLY MANUFACTURED and/or COMMERCIALLY PREPARED small
volume infusion bags of tranexamic acid).

Final containers (e.g., syringes, IV bags, repackaged vials) of pharmacy-prepared
(not aNEStHESIa PrOVIDEr-prepared) neuromuscular blocking agents include a
clearly visible warning (e.g., “Warning: Paralyzing agent—Causes respiratory
arrest;” “Warning: Causes respiratory Paralysis—Patient Must be
Ventilated”) that does not obscure important label information to communicate
that respiratory paralysis will occur and ventilation is required.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

continued on page 43

43

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element IV: Drug Labeling, Packaging, and Nomenclature (continued)

73

FaQ

74

75

Storage bins and/or ADC pockets, drawers, kits, and/or trays containing neuromuscular blocking agents include an auxiliary label to clearly communicate that
respiratory paralysis will occur and ventilation is required (e.g., “Warning:
Paralyzing agent—Causes respiratory arrest;” “Warning: Causes
respiratory Paralysis—Patient Must be Ventilated”).

a

b

C

D

E

Scoring guideline: Compliance can also be achieved by affixing an auxiliary warning
label (in addition to the manufacturers’ warning on the cap and ferrule) directly on all
vials and/or other containers stocked in the storage locations, or by displaying a warning on an ADC screen, which must be acknowledged prior to removal of a neuromuscular blocking agent—score accordingly.

Perioperative settings only purchase and use COMMErCIaLLy PrEParED (e.g., 503B
outsourcing facility prepared) products that follow USP <7> labeling practices,
which require the total amount of drug per total volume to be the primary display
of strength, followed by the per mL amount in parentheses.

Scoring guideline: Choose Not Applicable only if: a) COMMErCIaLLy PrEParED products
are never purchased or used by your facility; instead, pharmacy-prepared syringes are
used in the perioperative setting; or b) COMMErCIaLLy PrEParED products are never purchased or used by your facility; instead, practitioner-prepared syringes are used in the
perioperative setting.

Lipid-based lubricants (e.g., Rotaglide, ViperSlide) used during atherectomy procedures, knee arthroplasties, or cardiac catheterizations never enter the anesthesia workspace and are never available on the same work surface as propofol
or small volume infusion bags of intralipids; and these lubricants are introduced
to the sterile field only after induction of sedation or anesthesia.

NOT APPLICABLE

Core Characteristic # 5

Readable labels that clearly identify drugs are on all drug containers in the perioperative setting, and drugs remain
labeled up to the point of actual drug administration.

76
77

Medication storage bins, trays, kits, drawers, shelves, and compartments in the
perioperative setting are labeled using electronically generated labels that
include, at a minimum, the generic medication name (using taLL MaN LEttErINg, as
appropriate) and concentration; handwritten labels are not used.
Preprinted sterile labels, or sterile blank labels and smudge-proof markers, are
used for labeling medications/solutions on the sterile field during medical and/or
surgical procedures.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 44

44

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element IV: Drug Labeling, Packaging, and Nomenclature (continued)

78

In the PrEOPEratIVE HOLDINg arEa and in the POSt-aNEStHESIa CarE UNIt or recovery area,
practitioners are provided with preprinted or blank medication and solution labels;
and practitioners label each medication or solution they prepare with, at a minimum, the drug or solution name, strength/concentration, amount of medication (or
solution that contains medication) if not apparent from the container (e.g., syringe
or medicine cup without measurement increments), the diluent (if used) name and
volume if not apparent from the container, and the expiration date and time when
not used within 24 hours or when expiration occurs in less than 24 hours.

a

b

C

D

E

Exception: The date and time are not necessary for short procedures, as defined by
the facility.

79
80

81

The containers (e.g., syringes, medicine cups, basins) holding medications and
solutions (e.g., lidocaine, contrast, methylene blue, thrombin) on the sterile field
are labeled immediately after filling (i.e., labels are not applied to empty containers before filling), even if only one medication or solution is present.
The labels of practitioner-prepared medication and solution containers
(e.g., syringes, medicine cups, basins) on the sterile field are free of ErrOr-PrONE
abbrEVIatIONS, including drug name abbreviations.

The labels on practitioner-prepared medication and solution containers
(e.g., syringes, medicine cups, basins) on the sterile field include, at a minimum, the
drug or solution name, strength/concentration, amount of medication or solution
that contains medication if not apparent from the container (e.g., syringe, medicine cup, or basin without measurement increments), the diluent (if used) name
and volume if not apparent from the container, and the expiration date and time
when not used within 24 hours or when expiration occurs in less than 24 hours.

Exception: The date and time are not necessary for short procedures, as defined by
the facility.

82
83

Before affixing a sterile preprinted or handwritten label to the container of a medication or solution prepared on the sterile field, the label is compared visually to the
original container and read back to the circulating nurse verbally for confirmation.

For medications and solutions delivered to the sterile field during a medical
and/or surgical procedure, the original containers are kept in the OPEratINg rOOM
and/or PrOCEDUrE rOOM for reference and are not discarded until after the medical and/or surgical procedure has concluded.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 45

45

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element IV: Drug Labeling, Packaging, and Nomenclature (continued)

84

85
86

Syringes of medications prepared by aNEStHESIa PrOVIDErS are labeled with the
complete name and concentration/dose of the drug, and the expiration date and
time when the medication will not be used within 24 hours or when expiration
occurs in less than 24 hours. (An anesthesia color-differentiated drug class label
alone is not sufficient.)

a

b

C

D

E

Exception: Labeling is not required if the syringe is prepared immediately before drug
administration, never leaves the hand of the preparer before administration, and the
entire dose in the syringe is administered or the remaining volume is immediately
wasted or discarded before the syringe leaves the preparer’s hand. Expiration date and
time are not required for short procedures, as defined by the facility.
The labels of medication syringes prepared by aNEStHESIa PrOVIDErS and other perioperative practitioners are free of ErrOr-PrONE abbrEVIatIONS.

ELaStOMErIC PUMPS initiated for patients in the perioperative setting are labeled
with the name of the drug, concentration, infusion rate (mL per hour and dose
per hour), and start date.

Exception: Infusion rate and dose should not be included on the label if they might
change due to titration to effect (e.g., increased or decreased due to pain level).

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 46

46

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution
a

b

C

D

E

Core Characteristic # 6
IV and REGIONAL ANESTHESIA solutions, drug concentrations, doses, and administration times are standardized whenever
possible.

87
88

89

90
91
FaQ

92
a

b

The facility has established standard concentrations for adult and/or
neonatal/pediatric perioperative IV infusions of high-alert medications such as
morphine, heparin, insulin, vasopressors, and neuromuscular blocking agents,
which are used for 90% of adult and/or neonatal/pediatric patients.

The facility has established standard mixtures and concentrations for adult
and/or neonatal/pediatric NEUraXIaL aNEStHESIa, which are used for 90% of adult
and/or neonatal/pediatric patients.
Scoring guideline: Choose Not Applicable only if your facility never administers
NEURAXIAL ANESTHESIA.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if your facility never administers
peripheral nerve blocks.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if your facility never transfers patients
who have undergone a medical and/or surgical procedure to an inpatient critical care
unit within the same health system.

NOT APPLICABLE

The facility has established standard mixtures and concentrations for adult
and/or neonatal/pediatric peripheral nerve blocks, which are used for 90% of
adult and/or pediatric patients.

The facility has established standard drug concentrations and dosing units
between the OPEratINg rOOM/PrOCEDUrE rOOM and inpatient critical care unit(s)
within the same health system for infusions started in the OPEratINg rOOM/
PrOCEDUrE rOOM that are likely to continue in critical care units.

Standardized COMMErCIaLLy MaNUFaCtUrED solutions are used in the perioperative
setting for all IV hydrating solutions.

Standardized COMMErCIaLLy MaNUFaCtUrED, COMMErCIaLLy PrEParED, and/or
pharmacy-prepared (not perioperative practitioner-prepared) solutions are used
in the perioperative setting, unless they are needed in emergent situations, for
the following:

Score Each Item
Individually

IV medication infusions

rEgIONaL aNEStHESIa infusions (excluding bOLUS DOSES)

Scoring guideline: Choose Not Applicable only if
never used in your facility.

REGIONAL ANESTHESIA

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

infusions are

NOT APPLICABLE

continued on page 47

47

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

c
d
e
f

FaQ

93

Parenteral local anesthetics used during eye surgery

Scoring guideline: Choose Not Applicable only if eye surgeries requiring local
anesthetics are never performed in your facility.
Irrigation and flush solutions (e.g., heparinized saline)

a

b

C

D

E

NOT APPLICABLE

ELaStOMErIC PUMP medications and solutions

Scoring guideline: Choose Not Applicable only if ELASTOMERIC PUMPS are never used in
your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if cardioplegic solutions are never used
in your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if adult patients never undergo medical and/or surgical procedures in your facility.

NOT APPLICABLE

Cardioplegic solutions

For adults, COMMErCIaLLy MaNUFaCtUrED, COMMErCIaLLy PrEParED, and/or pharmacyprepared prefilled syringes of medications (e.g., neuromuscular blocking agents,
opioids, induction agents, tranquilizers, vasopressors, anticholinergics) are used
in the perioperative setting (including by aNEStHESIa PrOVIDErS) for at least 80% of
all adult medications administered from a syringe; perioperative practitionerprepared syringes of medications are avoided whenever possible.

For neonates/pediatric patients, COMMErCIaLLy MaNUFaCtUrED, COMMErCIaLLy
and/or pharmacy-prepared prefilled syringes of medications (e.g., neuromuscular blocking agents, opioids, induction agents, tranquilizers, vasopressors,
anticholinergics) are used in the perioperative setting (including by aNEStHESIa
PrOVIDErS) for at least 80% of all neonatal/pediatric medications administered from
a syringe; perioperative practitioner-prepared syringes of medications are avoided
whenever possible.
PrEParED,

FaQ

94

Scoring guideline: Choose Not Applicable only if neonates and/or pediatric patients
never undergo medical and/or surgical procedures in your facility.

Core Characteristic # 7

NOT APPLICABLE

Medications are provided to and stocked in perioperative settings in a safe and secure manner and are available for
administration within a time frame that meets essential patient needs.

95
96

Perioperative medication storage areas, including ADCs and anesthesia medication trays, kits, and/or carts, have a standardized configuration; and all medications, including different forms and concentrations of the same medication, are
stored in separate compartments.
Perioperative medication storage locations, including ADCs and anesthesia medication trays, kits, and/or carts, are secured or locked except when in use.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 48

48

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

97

98

99

100
101
102
a
Or

102
b

Separate anesthesia trays, kits, and/or carts are used to store rEgIONaL aNEStHESIa
and gENEraL aNEStHESIa agents.

Scoring guideline: Choose Not Applicable only if your facility never provides REGIONAL
ANESTHESIA.

Specialty medications (e.g., concentrated potassium chloride, oxytocin, terbutaline, mannitol) that may be required by subspecialty aNEStHESIa PrOVIDErS
(e.g., anesthesia used for neurological, cardiovascular, obstetrical, transplant surgeries) are stored in separate carts; supplemental trays, kits, or drawers; or in
another manner that does not alter the standard storage configuration of routine
anesthesia medications or allow the subspecialty medications to become available for use outside of designated specialty cases.

a

b

C

D

E

NOT APPLICABLE

In perioperative settings, all appropriate antidotes, reversal agents, and rescue
agents, with directions for preparation and use, are readily available and easily
accessible; and protocols or coupled order sets permit their emergency administration to prevent patient harm. Examples of appropriate antidotes, reversal agents,
and rescue agents that should be available in perioperative settings include: methylene
blue and oxygen (to treat methemoglobinemia from oral anesthetic sprays or gels);
naloxone (opioid toxicity); flumazenil (benzodiazepine toxicity); dantrolene/Ryanodex
(malignant hyperthermia); lipid emulsion (local anesthetic systemic toxicity); glycopyrrolate and neostigmine (neuromuscular blocking agent reversal).

Benzocaine oral topical anesthetic spray used to suppress the gag reflex prior to
a medical and/or surgical procedure is provided only in a metered dose sprayer
container to help control the duration of each spray and the amount of medication applied, thus lessening the risk of methemoglobinemia.

Scoring guideline: Choose Not Applicable only if your facility never uses benzocaine
oral topical anesthetic spray.

An emergency code cart(s) is readily available in the perioperative setting in a
convenient location(s) that takes minimal time to bring to a patient’s bedside if
needed.

NOT APPLICABLE

If medical and/or surgical procedures are performed on both adults and children,
separate adult and pediatric emergency code carts are available and clearly
identified.

Scoring guideline: Choose Not Applicable for either 102a or 102b if both adults and
children never undergo medical and/or surgical procedures in your facility.
Or
If medical and/or surgical procedures are performed on both adults and children,
a universal emergency code cart is available with supplies and medications for
adult and pediatric patients in separate trays or drawers, which are clearly
identified.
Scoring guideline: Choose Not Applicable for either 102a or 102b if both adults and
children never undergo medical and/or surgical procedures in your facility.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

NOT APPLICABLE

continued on page 49

49

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

103
104
FaQ

105
106
107
108
109
110

Solutions intended for IV, neuraxial, or regional/local administration are not
stored or placed temporarily in warming cabinets intended for linens or irrigation
solutions.

a

b

C

D

E

In perioperative locations where anesthetic agents that may trigger malignant
hyperthermia (e.g., succinylcholine, inhalation agents) are used, the sterile water
for injection required for the preparation of dantrolene/Ryanodex is available in
vial(s) or a 2- or 3-liter bag, which is sequestered from other IV products in a malignant hyperthermia kit or cart; and if a 2- or 3-liter bag is in the kit or cart, it is
clearly labeled to avoid IV administration.
In perioperative locations where anesthetic agents that may trigger malignant
hyperthermia are used (e.g., succinylcholine, inhalation agents), a full dose of
dantrolene/Ryanodex (drug mixed with required diluent) can be prepared and
administered within 10 minutes of diagnosing a malignant hyperthermia event.
Perioperative practitioners, including nurses and aNEStHESIa PrOVIDErS, select the
anticipated medications needed for one case at a time, and prepare the medications immediately prior to the medical and/or surgical procedure (e.g., medications are not pre-drawn into syringes or prepared in communal infusion bags for
use during multiple cases or for cases throughout the day).
Perioperative practitioners never mix two or more medications into the same
syringe (e.g., ketamine and propofol) or IV infusion bag.

For patients undergoing rEgIONaL aNEStHESIa, a local anesthetic with a rapid onset
of action (e.g., lidocaine) is never mixed with a local anesthetic of longer duration
of action (e.g., bupivacaine) to prevent the risk of additive toxicity.

Multiple-dose vials (30 mL) of EPINEPHrine for injection (1 mg/mL) are NOT
stocked in, or provided to, the perioperative setting (they are only available in the
pharmacy).

Medications intended for topical use (e.g., topical thrombin) are never drawn into
a parenteral syringe.

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50

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

111
112

Presoaked EPINEPHrine pledgets, rather than 30 mL vials of EPINEPHrine, are
used for topical application during a medical and/or surgical procedure.

a

b

C

D

E

Irrigation solution containers stocked in, and/or dispensed to, perioperative settings are packaged in 2- or 3-liter bags, pour bottles, or other route-specific packaging to differentiate them from IV bags; and irrigation solutions and IV bags are
stored separately.

Core Characteristic # 8

Access to perioperative medications is restricted and controlled.

113
a
Or
113
b
Or
113
c

In facilities using PrOFILED aDCs: In the PrEOPEratIVE HOLDINg arEa and the POSt-aNEStHESIa CarE UNIt or recovery area, PrOFILED aDCs are used and require a pharmacist
to review preoperative and postoperative orders before medications can be
removed from the cabinet.

Exception: The full access/critical override mode can be used for urgent or lifesaving
situations where a delay would harm the patient.

Scoring guideline: Choose Not Applicable only if ADCs are not available in the
PREOPERATIVE HOLDING AREA or the POST-ANESTHESIA CARE UNIT or recovery area in your facility.
Or
In facilities using aUtOVErIFICatION procedures: In the PrEOPEratIVE HOLDINg arEa
and the POSt-aNEStHESIa CarE UNIt or recovery area, aUtOVErIFICatION procedures are
in place for removal of all or certain medications from an ADC based on organization-defined inclusion criteria and protocols; and a pharmacist retrospectively
reviews preoperative and postoperative medication orders.

NOT APPLICABLE

Exception: The full access/critical override mode can be used for urgent or lifesaving
situations where a delay would harm the patient.

Scoring guideline: Choose Not Applicable only if ADCs are not available in the
PREOPERATIVE HOLDING AREA or the POST-ANESTHESIA CARE UNIT or recovery area in your facility.
Or
In facilities using non-profiled aDCs: In the PrEOPEratIVE HOLDINg arEa and the
POSt-aNEStHESIa CarE UNIt or recovery area, medications are obtained from nonprofiled ADCs; and a pharmacist retrospectively reviews preoperative and postoperative medication orders.

NOT APPLICABLE

Exception: The full access/critical override mode can be used for urgent or lifesaving
situations where a delay would harm the patient.

Scoring guideline: Choose Not Applicable only if ADCs are not available in the PREor the POST-ANESTHESIA CARE UNIT or recovery area in your facility.

OPERATIVE HOLDING AREA

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

continued on page 51

51

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

114

FaQ

115

116
117
118
119
120
121

In the PrEOPEratIVE HOLDINg arEa and the POSt-aNEStHESIa CarE UNIt or recovery area,
a medication order (e.g., electronic, written, verbal/telephone) is obtained (or an
approved protocol is in effect) prior to removing any medication from unit stock,
including prior to removing medications from ADCs (if available), even if they are
removed using the override function.

a

b

C

D

E

In the PrEOPEratIVE HOLDINg arEa and the POSt-aNEStHESIa CarE UNIt or recovery area,
interactive ADC alerts require users to enter or select clinically relevant information (e.g., purpose for drug removal, confirmation of required continuous electronic monitoring of oxygenation and/or ventilation, verification that the patient
is ventilated [for neuromuscular blockers]) prior to removal of certain organization-identified medications.

Scoring guideline: Choose Not Applicable only if ADCs are not available in the PREOPERATIVE HOLDING AREA or the POST-ANESTHESIA CARE UNIT or recovery area in your facility.

Refrigerated and nonrefrigerated neuromuscular blocking agents stored inside
OPEratINg rOOMS and/or PrOCEDUrE rOOMS, including in aNEStHESIa PrOVIDEr supplies
and ADCs, are segregated from other medications, with different agents each
stored in a separate compartment or drawer.

NOT APPLICABLE

Refrigerated and nonrefrigerated neuromuscular blocking agents stored in perioperative settings outside of OPEratINg rOOMS and PrOCEDUrE rOOMS (e.g., anesthesia workrooms, PrEOPEratIVE HOLDINg arEa, POSt-aNEStHESIa CarE UNIt) are
sequestered in a rapid sequence intubation kit and/or segregated from other
medications, with different agents each stored in a separate lidded compartment
or drawer.

Processes are in place in perioperative settings for managing expiration dates of
refrigerated medications that may be temporarily stored outside of refrigeration
(e.g., neuromuscular blocking agents).

In anesthesia trays, kits, carts, and/or drawers, the quantity of medications (e.g.,
vials, ampules, syringes) is limited to the amount needed to meet essential
patient needs between replenishment (e.g., not to exceed 72 hours); and the variety of different medication concentrations and formulations is restricted.

The placement of topical thrombin on the sterile field is delayed whenever possible until after all parenteral products have been administered; and once clearly
labeled topical thrombin has been placed on the sterile field, it is sequestered or
separated from any parenteral products that are open or immediately available
for use on the sterile field.
To prevent an inadvertent bolus of any residual drug remaining in the IV tubing
following drug administration, IV administration sets are immediately flushed (or
the IV sets are changed) at the rate recommended by the manufacturer, documented in peer reviewed literature, or approved by the organization.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
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52

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

122

123

124

125

126

127

All continuous IV medications and epidural infusions (e.g., continuous infusions of
magnesium, neuromuscular blocking agents, opioids) and associated administration sets are immediately discarded after discontinuation (and not left to hang on
an IV pole or at the bedside).

a

b

C

D

E

CONtrOLLED MEDICatIONS are retrieved by the aNEStHESIa PrOVIDEr, NON-aNEStHESIOLOgISt SEDatION PraCtItIONEr, or other practitioner who will be administering the medication; and removal of CONtrOLLED MEDICatIONS occurs immediately prior to each
medical and/or surgical procedure.

Exception: In rare emergent situations when more CONTROLLED MEDICATIONS are
required than originally anticipated, it is acceptable to ask another practitioner to
retrieve and bring the medications to the administering practitioner, if they are unable
to leave the patient.

A process is followed for wasting and disposing of the unused portion of
CONtrOLLED MEDICatIONS, and/or for securing and returning unused CONtrOLLED
MEDICatIONS to their secure storage location per organizational policy, immediately
after each medical and/or surgical procedure.

Practitioners never place medications (e.g., vials, syringes of prepared medications),
including CONtrOLLED MEDICatIONS, in their pockets.

Exception: In emergent or urgent conditions, a provider may place a potentially lifesaving medication in a pocket while transporting a patient from one perioperative care area
to another (e.g., OPERATING ROOM to POST-ANESTHESIA CARE UNIT) if their hands are not free.
However, organizational policy to allow this exception must be based on a thorough risk
assessment that supports this decision.
FentaNyL transdermal patches are not stocked in perioperative unit stock, including ADCs, and are not used to treat acute or postoperative pain.

Scoring guideline: Choose Not Applicable only if fentaNYL patches are never stocked
or used in your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if organ harvesting never occurs in
your facility.

NOT APPLICABLE

Organ preservation solutions used during organ harvesting are labeled with an
appropriate warning (e.g., “Organ Harvest Use Only”) and brought into the perioperative area immediately before needed and/or stored in sealed kits or locked
storage areas and obtained from storage immediately before use; and once the
procedure has been completed, there is an effective process to return any
unused preservation solutions to their secure locations or to immediately dispose
of partially empty bags.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

continued on page 53

53

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

128

129

Vials of concentrated potassium chloride or high-dose potassium cardioplegic
solutions are sequestered in sealed kits or locked storage areas and obtained
immediately before use; and once the procedure has been completed, there is an
effective process in place to return unused products to their secure locations
and/or dispose of the partially empty vials or bags.

a

b

C

D

Scoring guideline: Choose Not Applicable only if your facility does not perform
cardiac surgery that requires stopping the heart, or if your facility uses an alternative
to potassium chloride to stop the heart during surgery (e.g., adenosine, lidocaine,
magnesium solutions).

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if cardioplegic solutions are never used
in your facility.

NOT APPLICABLE

Availability of cardioplegic solutions used in the perioperative setting is restricted
to only certain perioperative suites that require its use (e.g., cardiac bypass
surgery).

Core Characteristic # 9

E

HAZARDOUS DRUGS, chemicals, and potentially flammable products used in the perioperative setting are safely prepared,
dispensed, stored, and administered.

130
a

b
c

d
e
f

g

h

A protocol based on USP <800> is in place and followed to address the safe
preparation, handling, transport, storage, administration, disposal, and management of spills of HazarDOUS DrUgS used in the perioperative setting, which
includes:

Score Each Item
Individually

Identifying a list of HazarDOUS DrUgS commonly used in the perioperative setting
(see definition of HazarDOUS DrUgS for examples)

Alerting perioperative practitioners to which HazarDOUS DrUgS are being used in
the perioperative setting and when special precautions are needed
Requiring preparation of HazarDOUS DrUgS in COMMErCIaLLy MaNUFaCtUrED, COMMErCIaLLy PrEParED, and/or pharmacy-prepared, ready-to-use containers
Requiring auxiliary warning labels for HazarDOUS DrUgS

Safe delivery, transport, and storage of HazarDOUS DrUgS

Preventing surface contamination and personnel exposure (e.g., personal protective equipment) to HazarDOUS DrUgS
Managing HazarDOUS DrUg spills

Outlining disposal procedures for HazarDOUS DrUgS (e.g., infusion bag, administration set, leftover products)

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
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54

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element V: Drug Standardization, Storage, and Distribution (continued)

i

131

132
133

Monitoring staff who are exposed to HazarDOUS DrUgS, on the basis of their job
duties, via a confidential medical surveillance program that assesses and documents symptom complaints, physical findings, and laboratory values (e.g., blood
count)

a

b

C

D

E

Antineoplastic agents, including Bacillus Calmette-Guêrin (BCG) and cancer
immunotherapies, and other HazarDOUS DrUgS to be administered during a medical and/or surgical procedure are prepared following USP <800> requirements
and transported to the OPEratINg rOOM or PrOCEDUrE rOOM immediately before the
beginning of the procedure.
Scoring guideline: Choose Not Applicable only if your facility never administers antineoplastic agents (including BCG, cancer immunotherapies) or other HAZARDOUS DRUGS.

A plan exists and is followed to reduce the risk of surgical fires in the OPEratINg
and/or PrOCEDUrE rOOM, including specific procedures for the safe use of
flammable, alcohol-based skin prep solutions (e.g., use of prefilled applicators or
small prep kits or sponges to limit pooling, soaking up spilled or pooled solutions,
adequate drying time before draping).

NOT APPLICABLE

rOOM

Glacial acetic acid (greater than or equal to 99.5% acetic acid) is not available in
the pharmacy or in the perioperative setting for use after dilution in certain medical and/or surgical procedures; instead, vinegar (5% solution) or a COMMErCIaLLy
MaNUFaCtUrED, diluted acetic acid 0.25% (for irrigation) or 2% (for otic use) is available or dispensed.

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55

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VI: MEDICatION DELIVEry DEVICE acquisition, Use, and Monitoring
a

Core Characteristic # 10

b

C

D

E

The potential for HUMAN ERROR is mitigated through careful procurement, maintenance, use, and standardization of
devices used to prepare and administer medications in the perioperative setting.

134
135

136
137

138

Labels with the name of the drug being infused and route of administration are
affixed to each access line (e.g., IV, epidural, bladder installations) at the distal end
closest to the patient and above each pump or channel.

When parenteral infusions are started, reconnected, or changed (new bag or
syringe), or the rate is adjusted, the tubing is traced by hand from the solution
container, to the pump, and then to the patient for verification of the proper
pump/channel and route of administration.
Infusion pumps (including syringe pumps) used for epidural infusions are standardized throughout the facility, specifically configured for epidural administration, visually distinguishable from those used for IV administration, and labeled or
visually identified as delivering epidural infusions.

Scoring guideline: Choose Not Applicable only if your facility never administers
epidural infusions.

Administration sets with yellow-striped tubing and without injection ports are
used for all epidural infusions, and not for any other purpose than for epidural
infusions.

Policies, protocols, and/or guidelines are in place to guide the care of patients
with a continuous subcutaneous insulin infusion device (insulin pump) and/or
continuous glucose monitor prior to, during, and immediately after a medical
and/or surgical procedure, which include an evaluation to determine the appropriateness of continuing insulin delivery via the pump, how to avoid exposure of
the pump to ionizing radiation or magnetic fields during imaging procedures, distance for required separation between the pump and common radio frequency
emitters used in the perioperative settings that might cause interference, and
how to manage the pump when the patient is not able to do so.
Scoring guideline: Choose Not Applicable only if you never allow patients to use a continuous subcutaneous insulin infusion device (insulin pump) and/or a continuous glucose monitor while present in your facility.

139
a
b

NOT APPLICABLE

Use of SMart INFUSION PUMP tECHNOLOgy with an engaged DOSE ErrOr-rEDUCtION
is expected by leadership and implemented in all perioperative settings,
including intraoperatively by aNEStHESIa PrOVIDErS and other practitioners, for the
following:
SyStEM

NOT APPLICABLE
Score Each Item
Individually

Continuous medication infusions

Intermittent and secondary infusions

Exception: GRAVITY INFUSIONS may be used for intermittent and secondary infusions
used only as a carrier fluid.

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56

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VI: MEDICatION DELIVEry DEVICE acquisition, Use, and Monitoring (continued)

c
d

140

141

142

a

rEgIONaL aNEStHESIa infusions

C

D

E

IV hydrating solution infusions

Exception: GRAVITY INFUSIONS may be used for IV hydrating solutions if they are only
used as a flush solution or if used for fluid resuscitation and the required rate of
infusion is greater than the pump allows.

Upper and lower HarD LIMItS for medication doses, concentrations, infusion rates,
and LOaDINg DOSES and bOLUS DOSES (if a bOLUS DOSE feature is available) have been
set in the drug library for SMart INFUSION PUMP tECHNOLOgy used in perioperative
settings, including in the OPEratINg rOOM and/or PrOCEDUrE rOOM.
Scoring guideline: Choose Not Applicable for each item only if your facility never uses
SMART INFUSION PUMP TECHNOLOGY in the perioperative setting.

aNEStHESIa PrOVIDErS and/or other perioperative practitioners administer LOaDINg
and/or bOLUS DOSES only by a hand-held syringe or via the bOLUS DOSE feature
available with SMart INFUSION PUMP tECHNOLOgy (with MaXIMUM DOSE limits configured as HarD StOPS), which automatically starts/resumes the maintenance infusion
at the prescribed rate once the LOaDINg DOSE or bOLUS DOSE has been infused;
LOaDINg DOSES and/or bOLUS DOSES are never administered via a maintenance/
continuous infusion by simply increasing the rate of infusion and/or using the
basic infusion mode.

NOT APPLICABLE

DOSES

Data from SMart INFUSION PUMP tECHNOLOgy used in the perioperative setting are
regularly reviewed and analyzed by an interdisciplinary team including perioperative practitioners:

Scoring guideline: Choose Not Applicable for each item only if your facility never uses
SMART INFUSION PUMP TECHNOLOGY in the perioperative setting.
ErrOr-rEDUCtION SyStEMS

a

At least monthly to evaluate DOSE
medication and hydrating solution

b

At least quarterly to monitor the alerts (e.g., SOFt LIMItS, HarD LIMItS, clinical alerts,
infusion parameters [dose, dose-rate, concentration, duration]) and actions taken
in response to the alerts (e.g., percent of reprogrammed alerts, percent of overridden alerts, switch to a basic infusion without DOSE ErrOr-rEDUCtION SyStEMS,
canceled/abandoned infusions)

c

b

compliance by

To develop perioperative-specific improvement plans (e.g., update the library,
address nuisance alerts, modify clinical workflow or procedures, identify opportunities for additional education) to remove or reduce barriers to the proper use
of SMart INFUSION PUMP tECHNOLOgy

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

Score Each Item
Individually

NOT APPLICABLE

NOT APPLICABLE

NOT APPLICABLE

continued on page 57

57

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VI: MEDICatION DELIVEry DEVICE acquisition, Use, and Monitoring (continued)

143
144
145
146
147

148

FaQ

149

Representatives from healthcare industry device companies are permitted to
program, calibrate, integrate, and synchronize MEDICatION DELIVEry DEVICES only
under the direct supervision of the facility practitioner responsible for the patient
and implanted device, and they are present only to advise the perioperative
team, never to assist directly in the sterile field (never scrub in for a procedure).

a

b

C

D

E

Pharmaceutical vendors and prescribers are prohibited from distributing drug
samples in the perioperative setting.
Perioperative practitioners who may use specific MEDICatION DELIVEry DEVICES are
involved in the decisions surrounding their selection and utilization, and patient
safety is one of the primary factors among others (e.g., effectiveness, usability,
reliability, heuristics, design) when making these decisions.
All gas cylinders, flow meters, and wall outlets utilize a Pin Index Safety System,
Diameter Index Safety System, or other system to avoid cross utilization.

Specifically designed ENFit and/or oral syringes distinctly marked “Enteral Use
Only” or “Oral Use Only,” which cannot be connected to parenteral tubing, are
available in PrEOPEratIVE HOLDINg arEaS and POSt-aNEStHESIa CarE UNItS/recovery
areas; and oral or ENFit syringes (never a parenteral syringe) are used for dispensing and/or administering oral and enteral liquid medications that are not
available in COMMErCIaLLy MaNUFaCtUrED or COMMErCIaLLy PrEParED unit dose cups.
Deep peripheral nerve blocks are guided by an ultrasonographic image that
allows real-time visualization of anatomical structures, the progression of the
needle, and the spread of the injected local anesthetic.

Exception: Transtracheal and ankle blocks do not require ultrasonographic guidance.

Scoring guideline: Choose Not Applicable only if your facility never performs deep
peripheral nerve blocks.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if your facility never performs
neuraxial procedures (e.g., NEURAXIAL ANESTHESIA, neuraxial medication administration,
spinal tap).

NOT APPLICABLE

Plans are in place to transition to the new design standards (ISO 80369-6) for
small neuraxial NRFit connectors used on medical device tubing, which will not fit
into ports other than neuraxial, reducing the risk of misconnections.

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58

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VII: Environmental Factors, Workflow, and Staffing Patterns
a

Core Characteristic # 11

b

C

D

E

Medications are prescribed, transcribed, prepared, dispensed, and administered in the perioperative setting within an
efficient and safe workflow and in a physical environment that offers adequate space and lighting, and allows
practitioners to remain focused on the MEDICATION-USE PROCESS without distractions.
FaQ

150
151
a

b
c

d
152
153
154
155

Proper lighting (illumination levels of 90 to 150 foot-candles) is available in perioperative areas where medications are stored, prepared, checked, and administered.

Perioperative practitioners work in a physical environment that offers adequate
space to store, prepare, and/or administer medications, and monitor patients in
the following settings:

Score Each Item
Individually

PrEOPEratIVE HOLDINg arEa

OPEratINg rOOMS and PrOCEDUrE rOOMS
POSt-aNEStHESIa CarE UNIt/recovery

area

Pharmacy serving the perioperative setting

Scoring guideline: Choose Not Applicable only if your facility does not include an
internal pharmacy that serves the perioperative setting (e.g., some freestanding ASCs).

Facility-provided and/or personal mobile device (e.g., cell phones, pagers, tablets,
smart watches) use, and/or internet use, in the perioperative setting is limited to
patient care related activities.

NOT APPLICABLE

Alarms on monitors, SMart INFUSION PUMP tECHNOLOgy, anesthesia machines, and
other applicable technology are functional, activated, sufficiently audible, and
used in conjunction with direct patient observation and clinical assessment to
monitor the perioperative patient’s condition.

Default parameters for physiological monitors used in the perioperative setting
reflect patient demographics and clinical indications appropriate for the typical
patient population; and when a monitor has been discontinued, perioperative
practitioners immediately return the monitor to the default settings
(e.g., “discharge the patient,” “end the case”) so the monitor is ready for
reactivation with another patient.
Unauthorized access to USB ports on medical devices (e.g., SMart INFUSION PUMPS,
anesthesia machines), intended for connecting approved accessories or transferring/installing new data or software, is controlled by disabling the ports through
device settings or by using physical USB locks or similar devices.

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59

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VII: Environmental Factors, Workflow, and Staffing Patterns (continued)
Core Characteristic # 12

a

b

C

D

E

The complement of qualified, well-rested practitioners in the perioperative setting matches the clinical workload
without compromising patient safety.

156
a

b

c

FaQ

157
158
159
160
a
Or

160
b

Perioperative practitioners involved in the MEDICatION-USE PrOCESS are scheduled to
work:

Exception: Staffing for emergency add-on procedures is excluded; only staffing for
scheduled cases is included.

Score Each Item
Individually

No more than 12 consecutive hours in a 24-hour period

No more than five 8-hour shifts or three 12-hour shifts in a row without a day off
With a 30-minute break for each mealtime that occurs during their shift

A fatigue reduction plan is designed and followed for on-call perioperative
practitioners and/or those who have worked overtime that provides adequate
recovery time for staff between shifts and guides an appropriate and just
response when practitioners feel, or the organization determines, it is unsafe to
provide care during an immediately subsequent shift due to fatigue.
An adjusted case load, delay in procedures, or planned late arrival of a perioperative practitioner due to fatigue from working on call and/or overtime does not
result in DISCIPLINary SaNCtION or other punitive action.

A 1:1 nurse-patient ratio is maintained for patients in a POSt-aNEStHESIa CarE UNIt or
recovery area during the first 15 minutes or until the patient is hemodynamically
stable and has a stable airway, and until transfer if a patient has received an
opioid pain medication in the POSt-aNEStHESIa CarE UNIt or recovery area.

For facilities with a daily onsite pharmacist(s): At least one pharmacist works
in the perioperative area(s) performing clinical activities such as reviewing patient
records and drug orders, providing input into the selection and administration of
drugs, educating patients, monitoring the effects of medications on patients,
overseeing safe medication storage, and providing perioperative staff education.
Or
For facilities without a daily onsite pharmacist(s): A pharmacist regularly conducts medication safety rounds in perioperative settings, in accordance with state
and federal regulations and accrediting standards, to oversee safe medication
storage, preparation, and administration and to provide perioperative staff
education.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
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60

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VIII: Staff Competency and Education
Core Characteristic # 13

a

b

C

D

E

Perioperative practitioners receive sufficient orientation to the perioperative MEDICATION-USE PROCESS and undergo
baseline and annual competency evaluations of knowledge and skills related to safe medication practices.

161
162

163

164

165

166

Practitioners are educated about, and demonstrate current understanding of, the
SUrgICaL SaFEty CHECKLISt and/or a tIME-OUt process.

Role-playing and simulations of perioperative error-prone conditions
(e.g., syringe and infusion bag swaps, unlabeled syringes, problematic medication
packages and labels) and adverse events (e.g., emergencies, methemoglobinemia, malignant hyperthermia) are used as methodologies to orient and
educate perioperative staff about medication and patient safety.
Only a physician, dentist, podiatrist, CRNA, or certified anesthesiologist assistant
who is licensed and trained in the use of drugs causing DEEP SEDatION, qualified to
rescue patients from gENEraL aNEStHESIa or severe respiratory depression, and not
simultaneously involved in a medical and/or surgical procedure, is permitted to
administer medications which could lead to DEEP SEDatION (e.g., propofol, ketamine, etomidate) of non-ventilated patients, even if MODEratE SEDatION is intended.
(PALS and/or ACLS certification alone is not sufficient.)

NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS and perioperative practitioners who
administer MODEratE SEDatION are qualified by education, training, and licensure,
and have current certification in advanced airway assessment and management
appropriate for the patient population (e.g., PALS; ACLS; advanced trauma life
support [ATLS]; medical board certification/board eligible in emergency medicine,
critical care, pulmonary medicine, or anesthesia).

Perioperative practitioners who titrate MODEratE SEDatION agents and/or postoperative pain medications to effect have received training about each drug’s onset,
peak, and duration; how to determine whether a previous dose has taken full
effect before administering another dose; and to consider other drugs administered that might increase the risk of hypotension or sedation, to prevent overdoses caused by DOSE StaCKINg.
If a registered nurse is allowed to administer certain facility-defined MODEratE
agents, such administration occurs only within the scope of their professional practice and under the direct supervision of a physician, dentist, or podiatrist qualified by education, training, and credentialing to administer MODEratE
SEDatION.

SEDatION

Core Characteristic # 14

Practitioners involved in the perioperative MEDICATION-USE PROCESS are provided with ongoing education about perioperative
medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused.

167

During orientation of all practitioners participating in the MEDICatION-USE PrOCESS in
the perioperative setting, known perioperative medication safety risks and
reduction strategies are reviewed.

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61

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element VIII: Staff Competency and Education (continued)

168
169
170
171

At least quarterly, practitioners participating in the MEDICatION-USE PrOCESS in the
perioperative setting receive information about medication risks and errors that
could impact their practice, including those that have been reported by external
organizations; and strategies to minimize these risks and errors are discussed.

a

b

C

D

E

Perioperative practitioners receive education about new drugs added to the
formulary, including risks that could lead to errors and adverse events and riskreduction strategies.

Perioperative practitioners are educated about MEDICatION DELIVEry DEVICES used in
the perioperative setting (e.g., infusion pumps, ELaStOMErIC PUMPS, implantable
devices, pen devices, syringes, needles) and associated protocols, guidelines,
order sets, and restrictions before they are permitted to operate such devices or
manage patients who are using these devices.
Perioperative practitioners are educated about the safe preparation, handling,
transport, storage, administration, disposal, and management of spills of
HazarDOUS DrUgS that might be used in the perioperative setting.

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62

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

Key Element IX: Patient Education

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Core Characteristic # 15

a

b

C

D

E

Patients are included as active partners in their perioperative care and are educated about their medications and ways
to avert errors.

172

173

174

175

176
a
b

During the preoperative phase of care (e.g., pre-anesthesia testing visit, care in
the PrEOPEratIVE HOLDINg arEa), patients and/or caregivers are educated about the
types of medications they may be receiving before, during, and after the medical
and/or surgical procedure (e.g., preprocedure antibiotics, antiemetics, anesthesia
plan, pain management plan), and are encouraged to ask questions.

During the preoperative phase of care (e.g., pre-anesthesia testing visit, care in
the PrEOPEratIVE HOLDINg arEa), patients for whom PCA or PCEA is planned are educated about its use; and during the post-operative phase of care (e.g., care in the
POSt-aNEStHESIa CarE UNIt), the instructions for using PCA or PCEA are reviewed and
reinforced before being transferred out of the perioperative area.

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if PCA and/or PCEA is never offered in
your facility.

NOT APPLICABLE

Patients, caregivers, and visitors are educated about the dangers of any individual other than the patient activating the PCA or PCEA button to deliver a medication dose (i.e., PCA by proxy); and a warning label, “For Patient Use Only,”
appears on the cord or activation button for PCA or PCEA.

During each drug administration in the PrEOPEratIVE HOLDINg arEa and in the POSt-aNEStHESIa CarE UNIt or recovery area, nurses and other licensed perioperative practitioners provide patients and/or caregivers with the name of the drug, its general purpose,
the prescribed dose, and, during initial drug administration, important side effects.

Exception: Patients who are awakening but not alert in the POST-ANESTHESIA CARE UNIT or
recovery area can just be informed about the general purpose of drug administration
(e.g., for pain, for nausea).

When discharged home from the perioperative setting after a medical and/or
surgical procedure, patients and/or caregivers are provided with verbal and
up-to-date written information at an appropriate reading level and in their
preferred language about:

Score Each Item
Individually

Any newly prescribed postoperative or postprocedural medications (e.g., pain
medications, antibiotics), including the name, dose, route, frequency of use,
important side effects (e.g., impact on psychomotor and cognitive function),
secure storage, and proper disposal of unused PRN opioids and other as needed
medications
Proper use of any recommended over-the-counter medications (e.g., pain medications, stool softeners)

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63

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D

Key Element IX: Patient Education (continued)

c
d
e

177
178
179

E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Any ambulatory pump that will be delivering medication (e.g., implanted pump,
ELaStOMErIC PUMP) and management of the infusion site

Scoring guideline: Choose Not Applicable only if patients are never discharged with
an ambulatory pump.

When to resume or not to resume previous prescription and over-the-counter
medications taken before the medical and/or surgical procedure

a

b

C

D

E

NOT APPLICABLE

Symptoms of NEUraXIaL aNEStHESIa and/or epidural injection complications
(e.g., spinal hematoma, epidural abscess, post-dural puncture headache) and
what to do if any occur

Scoring guideline: Choose Not Applicable only if patients never receive
ANESTHESIA and/or epidural injections.

NEURAXIAL

Patients who are discharged after a medical and/or surgical procedure are accompanied by a responsible adult who agrees to drive the patient home (ride-hailing
services such as Uber, Lyft, and taxis are not acceptable); and staff reasonably confirm, before the medical and/or surgical procedure begins, that a responsible adult
will be available to observe the patient for the remainder of the day.

NOT APPLICABLE

Patients and/or the responsible adult staying with the patient after a medical
and/or surgical procedure are instructed to observe for signs of rebound sedation and/or paralysis, and when and how to seek immediate medical attention.

Special instructions are given to the adult responsible for neonates and/or
younger pediatric patients who will be transported home in a car safety seat
regarding the need to carefully observe the child’s head position to avoid airway
obstruction.

Scoring guideline: Choose Not Applicable only if neonates and/or younger pediatric
patients are never treated in your facility.

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

continued on page 62

64

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management
Core Characteristic # 16

a

b

C

D

E

A safety-supportive JUST CULTURE and model of shared accountability for safe SYSTEM DESIGN/REDESIGN and making safe
behavioral choices is in place and supported by perioperative leaders, managers, and the associated Board of
Trustees/Directors.

180
181

182
183
FaQ

184
185
FaQ

186
187
a

b

Patient safety is a fundamental core value in the organization, which is reflected
in the organization’s mission, vision, and value statements.

The perioperative setting is governed by a formal policy(ies) that outline the organization’s commitment to a fair and JUSt CULtUrE, defines individual and leadership/management accountabilities associated with behavioral choices and SyStEM
DESIgN/rEDESIgN, and provides an overview of the organization’s just response to
HUMaN ErrOr (CONSOLINg), at-rISK bEHaVIOr (COaCHINg), and rECKLESS bEHaVIOr
(rEMEDIaL aCtION/DISCIPLINary SaNCtION).

Perioperative leaders and managers have been educated about establishing
and/or maintaining a fair and JUSt CULtUrE of safety; and key accountabilities and
outcome measures (e.g., culture survey results) for establishing and/or maintaining a JUSt CULtUrE are included in their job descriptions (or position statements or
medical staff bylaws, if applicable) and performance appraisals.

Perioperative leaders and managers hold all practitioners equally accountable for
the quality of their behavioral choices, regardless of their professional discipline,
rank or position in the organization, experience, and/or financial importance.

Perioperative leaders and managers do not react to a harmful event by automatically punishing the person/people involved, nor do they ignore the same
behavior when the outcome is good; and leaders and managers do not wait until
harm occurs to redesign error-prone systems.

Perioperative leaders and managers anticipate that practitioners will occasionally
engage in at-rISK bEHaVIOrS; observe work daily for signs of this behavioral drift;
and manage at-rISK bEHaVIOrS through investigation, SyStEM rEDESIgN, changes in
the rewards that entice the behavior, and COaCHINg (not DISCIPLINary SaNCtION) of
individuals to see the risk associated with behaviors that work around the
problems they encounter.
DISCIPLINary

ErrOr.

SaNCtIONS

are not taken against a practitioner for making a

HUMaN

Perioperative practitioners have been educated about their important role in the
following key accountabilities; and these key accountabilities are included in their
job descriptions (or position statements or medical staff bylaws, if applicable) and
performance appraisals:

Score Each Item
Individually

Making safe behavioral choices rather than being perfect and never making
HUMaN ErrOrS (which are not behavioral choices)
Reporting at-rISK bEHaVIOrS, hazards, and errors (including close calls that are
immediately corrected)

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65

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management (continued)

c

Participating in event investigation and implementation of action plans

a

b

C

D

E

Core Characteristic # 17

Practitioners are stimulated to detect and report perioperative adverse events, errors (including close calls), hazards,
and observed AT-RISK BEHAVIORS; and interdisciplinary teams regularly analyze these reports as well as reports of perioperative errors that have occurred in other organizations to mitigate future risks.

188
189
190
191
192
193
a

b
c
d

Perioperative leaders and managers create a work environment where practitioners feel empowered and safe to report risks, errors, and barriers to care;
actively pose questions when challenges arise; and share their insights and
concerns about safety.

Perioperative leaders and managers are visible and accessible in perioperative
care units (e.g., PatIENt SaFEty LEaDErSHIP WaLKrOUNDS, SaFEty HUDDLES) to learn
about daily system failures, risks, and suggestions for error prevention.

Perioperative practitioners are actively involved in the organization’s reporting
program and report all identified medication errors (including close calls),
hazards, and system failures that stem from breakdowns in the environment,
staffing, technology, information management, and the supply of materials.
A defined process has been established and is followed to determine if a medical
and/or surgical procedure can continue after a medication error has been
identified.

Perioperative (or organizational) leaders have identified reliable sources
(e.g., patient safety organizations, regulatory/accrediting agencies, professional
organizations) of external medication safety alerts and/or recommendations; and
the leaders have established a systematic review of this information at least
quarterly to assess and address vulnerabilities to similar events.

The organization routinely reviews the following data and reports; and a convened interdisciplinary team, which includes at least one senior leader, investigates identified problems, learns their causes, and recommends/facilitates action
for improvement:

Score Each Item
Individually

Staff compliance with protocols, guidelines, and order sets related to selected
high-alert medications
Staff compliance with technology (e.g., barCODE SCaNNINg rates, activation of SMart
INFUSION PUMP tECHNOLOgy DOSE ErrOr-rEDUCtION SyStEMS, ADC overrides)

Technology alerts (e.g., MaXIMUM DOSES, serious drug interaction, allergies) associated with HIgH-aLErt MEDICatIONS used in the perioperative setting to determine
whether practitioners are responding to them appropriately

Internal reports of medication risks, errors, and adverse events in the perioperative setting

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
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66

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management (continued)

194
195
a
b
196
197
198
199
200

Close calls and hazards that have the potential to cause patient harm are considered for analysis.

The following investigative resources are used to identify risks or errors with medications used in the perioperative setting and to demonstrate sustained improvement after implementation of risk-reduction strategies:

a

b

C

D

E

Score Each Item
Individually

Use of reversal agents or antidotes (e.g., flumazenil, naloxone, vitamin K1, fresh
frozen plasma, lipid emulsion, prothrombin complex concentrates, dantrolene)

Clinical trIggErS (e.g., airway interventions, unplanned or prolonged hospitalization, inability to complete a procedure [sedation failures], opioid-induced
respiratory depression or unintended advancing sedation)
Risks and events that are investigated include analysis of what normally happens
to uncover how involved tasks are conducted under usual circumstances as
opposed to how the task has been designed according to a policy or procedure.
The perioperative MEDICatION-USE PrOCESS is analyzed at least every 2 years
(e.g., using a PrOaCtIVE rISK aSSESSMENt tool such as this self assessment) to
identify potential risk factors for medication errors.

Risks and errors that are investigated result in action plans, which are layered
with multiple, HIgH-LEVEragE rISK-rEDUCtION StratEgIES; and these action plans have
a realistic timeline for implementation that considers all available resources.

The scope of organizational learning from risks and errors, and the scope of interventions established in action plans, are widespread and include all areas with
similar risks, including perioperative areas.

Perioperative leaders and managers measure the implementation and effectiveness of action plans (e.g., measure compliance with new medication protocols,
drug use evaluations, random chart review using trIggErS, track risk priority
numbers from FMEAs, observational methods) without relying on practitionerreported events; and any necessary adjustments are made to action plans to
demonstrate sustained improvement over time.

Core Characteristic # 18

Redundancies that support a system of INDEPENDENT DOUBLE CHECKS or automated verification processes are used for
vulnerable parts of the perioperative MEDICATION-USE PROCESS to detect and correct serious errors before they reach
patients.

201
a

Prior to each medical and/or surgical procedure, the entire surgical or
procedural team actively participates in a SUrgICaL SaFEty CHECKLISt (or adaptation)
and/or a tIME-OUt process to confirm key aspects of the procedure, including (at a
minimum):

Score Each Item
Individually

Patient identity

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67

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management (continued)

b

Allergies and associated reactions

d

Procedure being performed and laterality (if applicable)

c

e

202

barCODE SCaNNINg technology is used by perioperative practitioners in the following perioperative locations:

b

c
d
203

C

D

E

Anesthesia plan

Other medications and doses to be administered during the procedure
(e.g., heparin, local anesthetics)

a

b

Preprocedure antibiotics (when required)

f

g

a

A patient monitoring and rescue plan (e.g., readily available rescue agent)

PrEOPEratIVE HOLDINg arEa to verify the patient and medications/solutions prior to
administration

Score Each Item
Individually

OPEratINg rOOMS by aNEStHESIa PrOVIDErS, NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS,
and/or other perioperative practitioners (e.g., surgeons, nurses) to verify
medications/solutions prior to administration

Scoring guideline: Choose Not Applicable only if your facility does not have any
OPERATING ROOMS.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable only if your facility does not have any
PROCEDURE ROOMS.

NOT APPLICABLE

PrOCEDUrE rOOMS by aNEStHESIa PrOVIDErS, NON-aNEStHESIOLOgISt SEDatION PraCtItIONErS,
and/or other perioperative practitioners (e.g., surgeons, nurses) to verify
medications/solutions prior to administration

POSt-aNEStHESIa CarE UNIt/recovery area to verify the patient and medications/
solutions prior to administration

If barCODE SCaNNINg technology is employed prior to administration of any perioperative medications and solutions, an interdisciplinary team reviews data from
the system, including the percent of medications with a readable barcode, scanning compliance rates, and bypassed or acknowledged alerts; and any barriers
with using the technology safely and effectively are addressed.
Scoring guideline: Choose Not Applicable only if your facility never uses BARCODE SCANtechnology prior to administration of any perioperative medication or solution.

NING

© 2020 - ISMP Medication Safety Self Assessment for Perioperative Settings
®

NOT APPLICABLE

continued on page 66

68

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management (continued)

204

and POStor recovery area, when selected high-alert medications (as
defined by the facility) are removed from unit stock (including ADCs), the medication and dose/concentration are INDEPENDENtLy DOUbLE CHECKED by another practitioner and documented before administration.
In the

b

C

D

E

aNEStHESIa CarE UNIt

In the

205

PrEOPEratIVE HOLDINg arEa, OPEratINg rOOM, PrOCEDUrE rOOM,

a

PrEOPEratIVE HOLDINg arEa, OPEratINg rOOM, PrOCEDUrE rOOM,

and/or

POSt-

aNEStHESIa CarE UNIt or recovery area, before starting selected facility-defined high-

alert medication infusions and at additional facility-defined steps (e.g., change of
shift, HaND-OFFS, change in the infusion rate/dose, change in the bag/bottle/
syringe), an INDEPENDENt DOUbLE CHECK is performed and documented to verify the
patient; the patient’s weight (for weight-based medications); the drug/solution,
concentration, dose, and infusion rate; channel selection; and line attachment.

Core Characteristic # 19

Proven infection control practices are followed in perioperative settings when storing, preparing, and administering
medications.

206
207
208
209

210
211
212

Healthcare providers in the perioperative setting use appropriate hand hygiene
procedures and standardized aseptic technique prior to preparing any injectable
product (e.g., IM, IV push).

A single syringe is never used for multiple patients, even if the needle is changed
between patients.

Single-dose vials are used for only one patient, even if medication remains in the
vial.

Containers of propofol (e.g., 10 mL, 20 mL, 50 mL, 100 mL), which are intended
for single patient use only, are never used to prepare doses for more than one
patient.

Exception: During a propofol shortage, larger containers of propofol may be withdrawn into syringes or transferred to smaller containers only in a pharmacy that is
compliant with sterile compounding regulations; and the syringes and smaller
containers are labeled with a beyond-use date.

If a multiple-dose vial enters an immediate perioperative patient treatment area
(e.g., OPEratINg rOOM, PrOCEDUrE rOOM, anesthesia and procedure carts, patient
room or bay), the vial is treated as a single-dose vial and used for a single patient
only.
Sterile caps are used on secondary or primary IV administration sets when disconnected from a catheter hub and intended for future use.

Parenteral (e.g., IV, neuraxial) medication infusions and hydrating solutions are
spiked immediately prior to administration, not hours in advance of need.

© 2020 - ISMP Medication Safety Self Assessment® for Perioperative Settings

69

a

There has been no activity to implement this item.

C

This item has been partially implemented for some or all patients, orders, drugs, or staff.

b

D
E

This item has been formally discussed and considered, but it has not been implemented.
This item is fully implemented for some patients, orders, drugs, or staff.
This item is fully implemented for all patients, orders, drugs, or staff.

Key Element X: Quality Processes and risk Management (continued)

FaQ

213
214
215
FaQ

216

FaQ

217
FaQ

218
219

Clear and consistent policies that address the discontinuation and/or continuation of parenteral nutrition (PN) during medical and/or surgical procedures have
been established and are followed, and the policies include guidance on appropriate metabolic monitoring of the patient during surgery.

a

b

C

D

An aseptic process is in place to transfer medications from vials/bags/bottles to
the sterile field.

Topical preparations used in perioperative settings (e.g., ophthalmic drops, lubricating jelly) are never used for multiple patients.

Perioperative practitioners caring for adult patients do NOT withdraw IV push medications from COMMErCIaLLy MaNUFaCtUrED, cartridge-type syringes into another
syringe for administration.

Scoring guideline: Choose Not Applicable if your organization never provides care to
adult patients, or if COMMERCIALLY MANUFACTURED, cartridge-type syringes are never available.

NOT APPLICABLE

Scoring guideline: Choose Not Applicable if your organization never provides care to
pediatric and/or neonatal patients, or if COMMERCIALLY MANUFACTURED, cartridge-type
syringes are never available.

NOT APPLICABLE

Perioperative practitioners caring for pediatric and/or neonatal patients do NOT
withdraw IV push medications from COMMErCIaLLy MaNUFaCtUrED, cartridge-type
syringes into another syringe for administration.

Perioperative practitioners never dilute or reconstitute an IV push medication by
drawing the contents into a COMMErCIaLLy MaNUFaCtUrED prefilled flush syringe of
0.9% sodium chloride.

A bag or bottle of IV solution or medication infusion (e.g., phenylephrine, insulin)
is never prepared and/or used outside the pharmacy as a source of flushes, diluents, or bOLUS DOSES for single or multiple patients.

© 2020 - ISMP Medication Safety Self Assessment® for Perioperative Settings

E

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Glossary
anesthesia personnel: aNEStHESIa PrOVIDErS as well as any
licensed practitioners or unlicensed personnel who work
under the direct supervision of aNEStHESIa PrOVIDErS, including anesthesia assistants and anesthesia technicians who
may assist (e.g., order, stock, and replenish medications
and supplies) aNEStHESIa PrOVIDErS with clinical (not business/billing) processes.

anesthesia provider: A licensed practitioner (e.g., anesthesiologist, CRNA, certified anesthesiologist assistant) who
is trained, qualified, and authorized within the organization
to plan and administer MaC, DEEP SEDatION, gENEraL aNEStHESIa, and/or rEgIONaL aNEStHESIa; monitor sedated and/or
anesthetized patients during procedures; support patients’
vital functions inclusive of hemodynamic stability and airway management during procedures; and diagnose and
treat pathologic changes and other clinical problems that
might occur during the perioperative period.

antithrombotic medication: Includes warfarin; heparin(s)
(e.g., unfractionated heparin, low molecular weight
heparin); factor Xa inhibitors (e.g., apixaban, betrixaban,
edoxaban, fondaparinux, rivaroxaban); direct thrombin
inhibitors (e.g., argatroban, bivalirudin, dabigatran); thrombolytics (e.g., alteplase, tenecteplase); and antiplatelet medications (e.g., abciximab, aspirin, clopidogrel, dipyridamole,
prasugrel, ticagrelor, ticlopidine).

at-risk behavior: Behavioral drift that occurs over time in
all humans after successful violations (no adverse outcomes) of a rule; a behavioral choice that increases risk
where the risk is not recognized or mistakenly believed to
be insignificant or justified. at-rISK bEHaVIOrS often occur
when individuals knowingly violate policies, procedures, or
generally accepted practices to work around unexpected
problems and system failures to accomplish their work in
the moment. Examples include bypassing a duplicate
therapy alert during order entry without due consideration;
technology workarounds; removing more than one
patient’s medications from an ADC prior to administration;
and written orders or documentation that include ErrOrPrONE abbrEVIatIONS. The just response to at-rISK bEHaVIOr is
to investigate the source and scope of the behavior; to
remove any barriers to the desired safer alternative choice;
and to COaCH (not DISCIPLINE) individuals to see the significant
risk associated with their choice and more appropriate
safer alternatives.

autoverification: EHR functionality which allows a medication order to be entered and released (automatically verified) in the EHR, bypassing the need for medication order

verification by a pharmacist and facilitating medication
administration.

barcode scanning: The use of optical machine-readable
representation of data found in barcodes on medication
packages and patient identification bands to verify that the
correct patient is receiving the correct medication, the correct solution or ingredient is selected prior to compounding
a preparation, or the correct medication is retrieved from
or stocked in the correct storage location. The process
involves the use of a barcode scanner, an electrical device
that can read and output printed barcodes to a computer.

basal infusion: A continuous infusion of an opioid to provide a constant level of analgesia, which may also be administered as bOLUS DOSES, PCA, or PCEA.

bolus dose: A discrete dose of medication or fluid given in
a set volume at the desired infusion rate or for a specified
duration prior to (see LOaDINg DOSE) or during a continuous
infusion.

Coach/coaching: Refers to a values-supportive, nondiscussion with a person who has misread risk
and engaged in an at-rISK bEHaVIOr, to help them see risk
that was not seen or misread as being insignificant or justifiable, and to help them understand the need to engage in
better behavioral choices.

DISCIPLINary

Commercially manufactured: A product available from a
commercial manufacturer.

Commercially prepared: A product available from an outsourced compounding facility (e.g., a 503B outsourcing
facility).
Computerized prescriber order entry (CPOE): Refers to
an inpatient and/or outpatient electronic computer system
into which an authorized prescriber enters medical orders.

Console/consoling: Refers to the act of comforting an individual who has made a HUMaN ErrOr to help alleviate any
sense of failure and loss, restore relationships and trust,
and promote forgiveness (of self and others) and healing.

Controlled medications: Medications or substances that
are categorized under the Controlled Substances Act and
which are regulated under state and federal law into five
“schedules,” depending on the substance’s medical use, the
potential for abuse, and safety or dependence liability.
Examples of classes of CONtrOLLED MEDICatIONS include

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opioids, depressants, stimulants, hallucinogens, and
anabolic steroids.

Deep sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but
respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory
function may be impaired. Patients may require assistance
in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained.

Disciplinary sanction/discipline: Punitive deterrent to
encourage an individual or group to refrain from undesired
behavioral choices.

Dose error-reduction system: Refers to the integral computer software in SMart INFUSION PUMPS intended to aid in
prevention of infusion programming-related errors and
warn users of potential over- or under-delivery of a medication or fluid by checking programmed doses/rates
against facility-configurable preset limits specific to a medication/fluid, and to a clinical application (e.g., epidural
administration) and/or location (e.g., neonatal intensive
care unit, medical/surgical unit).

Dose stacking: The administration of another dose of the
same medication or class of medication (e.g., MODEratE
SEDatION agents, pain medications) before the peak effect of
the previous dose/medication has been reached, which
could result in an excessive total drug effect over time. For
example, peak analgesic effect with morphine may not be
achieved for up to 2 minutes following IV administration.
DOSE StaCKINg is possible if more morphine is given before
the previous dose reaches its peak effect. However,
morphine may be titrated safely in certain settings
(e.g., immediate postoperative setting) every 5 minutes if
smaller bOLUS DOSES are used.  

Drug intolerance: An adverse drug reaction characterized
as a side effect (undesirable effect at recommended doses),
intolerance (low tolerance to an adverse effect), idiosyncrasy (genetically determined, abnormal reaction to a drug),
or toxicity (toxic reactions linked to excess dose and/or
impaired excretion), rather than a true drug allergy.

Elastomeric pump: A device (e.g., Ambu ACTion, ON-Q, ball
pump) used after certain procedures to intermittently or
continually infuse medications, typically local anesthetics, at
a specific rate into the tissues around an incision. The medication is held in a stretchable balloon reservoir (medication

reservoir ball), and pressure from the elastic walls of the
balloon drives the medication delivery, rather than gravity.

End-tidal carbon dioxide (EtCO2) monitoring (capnography): Breath-by-breath measurement of the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation
and provides an early warning about a worsening trend in
a patient’s condition caused by hypoventilation, hyperventilation, increased metabolic activity, decreased cardiac
output, and/or poor pulmonary perfusion.

Epidural anesthesia: A technique of managing pain in the
thoracic, lumbar, or sacral areas without the loss of consciousness, in which an opioid and/or anesthetic is injected
or infused into the peridural space through an indwelling
catheter. Administration may be a single injection, a continuous baSaL INFUSION, or self-administered (patientcontrolled) within programmed limits.
Error-prone abbreviations: Certain medical abbreviations, symbols, ratio expressions used for single-entity
products, drug name abbreviations, and dose designations
that are considered “dangerous” and have often contributed to serious medication errors. A complete list can
be found at: www.ismp.org/node/8.

general anesthesia: A drug-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance
in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired.

gravity infusion: Medication or fluid administered without
an infusion device or DOSE ErrOr-rEDUCtION SyStEMS, which
relies on the force of gravity to infuse and is manually controlled (e.g., with a roller clamp).

Hand-off: The real-time process of communicating all
pertinent patient information from one provider/team to
another provider/team as the responsibility of care is transferred (transitions of care) for the purpose of ensuring

continuity and safety. The process includes verification of
the shared information and an opportunity to ask questions and receive answers.

Hard limit/hard stop (within drug library): A medication
or fluid-specific forcing function that ensures that an

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infusion cannot be given outside facility-established medication or fluid-specific parameters (e.g., concentration,
dose-rate of continuous infusions, dose of intermittent
infusions, duration of intermittent infusions). These upper
(maximum) and lower (minimum) limits are set in the drug
library and cannot be overridden.

Hazardous drug: The National Institute for Occupational
Safety and Health (NIOSH) considers a drug to be
hazardous if it exhibits one or more of the following characteristics in humans or animals: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity,
organ toxicity at low doses, genotoxicity, or structure and
toxicity profiles of new drugs that mimic existing HazarDOUS
DrUgS. Examples of HazarDOUS DrUgS used in the perioperative setting include antineoplastic drugs such as
bevacizumab, gemcitabine, fluorouracil, methotrexate, and
mitoMycin; non-antineoplastic drugs that meet other
NIOSH criteria, such as azatHIOprine and carbaMazepine;
and drugs with reproductive hazards, such as fosphenytoin,
dronedarone, zidovudine, estrogen creams, fluconazole,
oxytocin, and progesterone.

High-leverage risk-reduction strategies: Refers to the
most effective risk-reduction strategies, which prevent,
restrict, or stop an identified risk with minimal reliance on
human vigilance and memory. HIgH-LEVEragE rISK-rEDUCtION
StratEgIES often require SyStEM rEDESIgN and a JUSt CULtUrE
to make systems more resistant to HUMaN ErrOr and enable
practitioners to make safe behavioral choices by removing
the system- and cultural-based incentives for cutting
corners. Examples of HIgH-LEVEragE rISK-rEDUCtION StratEgIES
include barriers that prevent carrying out tasks the wrong
way, strategies that “force” task completion the correct way
(forcing functions), engineering fail safes (e.g., free-flow protection with SMart INFUSION PUMPS), and technology such as
barCODE SCaNNINg to provide just-in-time decision support,
verify accuracy, and halt progress when errors are made.
Education and rules, while important, are not HIgH-LEVEragE
rISK-rEDUCtION StratEgIES and should not be relied on alone
to prevent errors.

High-risk patient (for respiratory depression): A pediatric or adult patient receiving a central nervous system
depressant (e.g., general anesthetic, sedative, opioid) who
has risk factors that increase the likelihood of respiratory
depression and associated adverse outcomes:
Age less than 6 months or greater than 55 years
Obesity
Hepatic or renal impairment

Known or suspected sleep-disordered breathing
(e.g., snoring, upper airway resistance syndrome,
obstructive sleep apnea-hypopnea syndrome)
Large neck circumference
Anatomical maxilla or mandible abnormalities
Prolonged surgery (greater than 2 hours)
Thoracic or upper abdominal surgical incisions that
may impair adequate ventilation
Pulmonary or cardiac disease or dysfunction or major
organ failure
Congenital central hypoventilation syndrome (pediatrics)
Myasthenia gravis
Ultra-rapid drug metabolism (genetic polymorphism)
Smoker
Concomitant administration of sedating agents
High opioid dose requirements
History of naloxone administration

Human error: Inadvertently doing other than what should
have been done; a mental slip, lapse, or mistake, such as
miscalculating a dose, forgetting to dilute a medication, or
transposing the doses of two antibiotics while prescribing
the medications. HUMaN ErrOrS are unintentional acts, not
behavioral choices; thus, the just response to HUMaN ErrOr
is to CONSOLE the individual and to investigate SyStEM rEDESIgN
to prevent/reduce reoccurrence.

Independent double check (independently double
checked): A procedure in which two individuals, preferably
two licensed practitioners, separately check each component
of the work process. An example would be one person calculating a medication dose for a specific patient and a second
individual independently performing the same calculation
(not just verifying the calculation) and matching the results. 

Invasive procedure: A procedure that penetrates the protective surfaces of a patient’s body, generally requiring
entry into a body cavity and/or insertion of an indwelling
foreign body; is performed in an aseptic surgical field; and
requires MODEratE SEDatION, DEEP SEDatION, MaC, rEgIONaL
aNEStHESIa, and/or gENEraL aNEStHESIa of the patient to
perform. Procedures that do not require sedation or anesthesia as listed above are not included in this definition.

Just Culture: Refers to a safety-supportive model of shared
accountability where healthcare institutions are accountable for the systems they design, for supporting the safe
behavioral choices of patients, visitors, and staff, and for
responding to staff behaviors in a fair and just manner. In
turn, staff are accountable for the quality of their behavioral

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choices (HUMaN ErrOr is not a behavioral choice) and for
reporting their errors and system vulnerabilities. 

Loading dose: The initial dose of a medication given by
infusion that is intended to rapidly achieve a therapeutic
level prior to initiating the continuous infusion or scheduled
maintenance dose infusion.

Maximum dose: The dose of a medication that represents
the upper limit that is normally found in the literature
and/or manufacturer recommendations. MaXIMUM DOSES
may vary according to age, weight, or diagnosis. 
Medication delivery device: An instrument/equipment
used to administer medications and solutions, including
programmable large volume and syringe infusion pumps,
PCA pumps, epidural infusion pumps, implantable pumps,
pen devices that contain medication (e.g., EPINEPHrine,
insulin), syringes, and dosing cups.  

Medication safety officer: A clinical practitioner designated
by an organization to serve as the authoritative leader in
safe medication use for the purpose of reducing patient
harm related to medication use. Other titles used to
describe this role include medication safety leader, medication safety manager, medication safety coordinator,
medication safety clinical specialist, medication safety
pharmacist or nurse, and director of medication safety.

Medication-use process: A series of clinical tasks and subtasks for managing the information, environment, and
human resources associated with all phases of medication
use, including medication procurement, prescribing, preparation, dispensing, administration, and patient monitoring.
The MEDICatION-USE PrOCESS consists of ISMP’s Key Elements of
the Medication Use System™ that form a framework for
managing medication use safely: 1) patient information;
2) drug information; 3) communication of drug orders and
other drug information; 4) drug labeling, packaging, and
nomenclature; 5) drug standardization, storage, and distribution; 6) MEDICatION DELIVEry DEVICE acquisition, use, and
monitoring; 7) environmental and workflow patterns;
8) staffing patterns and competency; 9) patient/caregiver
education; and 10) quality processes and risk management.
Moderate sedation: A drug-induced depression of
consciousness during which patients respond purposefully
to verbal commands, either alone or accompanied by light
tactile stimulation. No interventions are required to maintain
a patent airway, and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. MODEratE

SEDatION can be performed by a qualified individual, separate

from the proceduralist, so that vital functions can be continuously monitored and supported.

Monitored anesthesia care (MaC): A specific anesthesia
service used for medical and/or surgical procedures in
which a qualified aNEStHESIa PrOVIDEr continually monitors
and supports the patient’s vital functions; diagnoses and
treats clinical problems that occur; administers sedative,
anxiolytic, or analgesic medications to achieve varying
levels of sedation, awareness, and analgesia; and converts
to gENEraL aNEStHESIa if required.

Neuraxial anesthesia: A type of rEgIONaL aNEStHESIa
(excluding peripheral nerve blocks) that involves injection
of one or more opioids and/or anesthetic medications by
the epidural or intrathecal (spinal) routes of administration
to manage pain in the thoracic, lumbar, or sacral region,
without loss of consciousness. NEUraXIaL aNEStHESIa
includes EPIDUraL aNEStHESIa and SPINaL aNEStHESIa.

Non-anesthesiologist sedation practitioner: A licensed
physician, dentist, or podiatrist who has not completed
postgraduate training in anesthesiology but is specifically
trained to personally administer and supervise the administration of MODEratE SEDatION.
Non-controlled medications: Medications that are not
controlled under the Controlled Substances Act (e.g., neuromuscular blockers, reversal agents, vasopressors, hypotensive agents, anticholinergics, antiemetics, antibiotics,
steroids, electrolytes, blood glucose regulators, gastrointestinal agents, bronchodilators, anticoagulants).

Operating room: A specially equipped room that meets
the requirements of a rEStrICtED arEa and is designated and
equipped for performing medical and/or surgical procedures, that require an aseptic field. Any form of anesthesia
may be administered in an OPEratINg rOOM as long as
appropriate anesthesia gas administration devices and
exhaust systems are provided. A hybrid OPEratINg rOOM is
included in this definition (an OPEratINg rOOM that has
permanently installed equipment [not portable imaging
technology] to enable diagnostic imaging before, during,
and after medical and/or surgical procedures).

Opioid-naïve patient (adult): Patients who do NOT meet
the definition of OPIOID-tOLEraNt, and thus have NOT been
receiving for 1 week or longer, at least: 60 mg oral
morphine/day; 25 mcg transdermal fentaNyL/hour; 30 mg
oral oxyCODONE/day; 8 mg oral HyDrOmorphone/day;

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25 mg oral oxyMOrphone/day; 60 mg oral HyDrOcodone/day; or an equianalgesic dose of another opioid,
including heroin and/or non-prescribed opioids.

Opioid-tolerant patient (adult) (opioid tolerance): OPIOID
is defined by the following markers: Patients
receiving, for 1 week or longer, at least: 60 mg oral
morphine/day; 25 mcg transdermal fentaNyL/hour; 30 mg
oral oxyCODONE/day; 8 mg oral HyDrOmorphone/day;
25 mg oral oxyMOrphone/day; 60 mg oral HyDrOcodone/day; or an equianalgesic dose of another opioid,
including heroin and/or non-prescribed opioids.

tOLEraNCE

Patient Safety Leadership Walkrounds: Weekly rounds
by senior leaders in patient care units, designed to open the
lines of communication about patient safety among leaders
and staff so learning can occur, and to demonstrate leadership’s commitment to safety and communicate its value in
the organization. FaQ

Post-anesthesia care unit: A unit (sometimes called the
recovery room or area) that provides a safe environment
where immediate care of patients who have undergone a
medical and/or surgical procedure can be closely monitored by specially trained practitioners for the return of protective airway reflexes and early recognition and treatment
of anesthesia and/or procedural side effects and instability,
including airway compromise, respiratory depression,
bleeding and other hemodynamic instability, nausea,
vomiting, delirium, and pain control.

Preoperative holding area: Any location where practitioners prepare patients and conduct a preprocedure
assessment (e.g., vital signs, medication history, airway
assessment, general health assessment) of the patient on
the day of their scheduled medical and/or surgical
procedure, before the procedure begins.

Proactive risk assessment: The process of identifying and
systematically analyzing the risk and hazards embedded in
the process and structure of care to prevent adverse events
from occurring. Understanding the risk and hazards helps
to inform the design, planning, and development of appropriate system interventions that will eliminate or minimize
risks and hazards before patient injuries occur. 

Procedure room: A room designated for the performance
of medical and/or surgical procedures that requires highlevel disinfection or sterile instruments and some environmental controls but is not required to be performed with
the environmental controls of an OPEratINg rOOM.

Profiled aDC: Functionality that allows an ADC to be
interfaced with the pharmacy computer system and EHR,
thereby restricting the removal of a medication from the
ADC until after a pharmacist has verified the safety of the
order. Once pharmacy verification has occurred, a practitioner can select the medication from a patient-specific list
on the ADC screen and remove the medication from the
ADC.

reckless behavior: A behavioral choice to consciously
disregard a substantial and unjustifiable risk. (Conscious
disregard of a policy or procedure, rather than conscious
disregard of a significant risk, is often an at-rISK bEHaVIOr,
not rECKLESS bEHaVIOr.) rECKLESS bEHaVIOrS occur when people
put their own needs ahead of the needs of patients, the
organization, and/or their colleagues. An example includes
drug diversion. The just response to rECKLESS bEHaVIOr is
typically rEMEDIaL aCtION or DISCIPLINary SaNCtION.
regional anesthesia: Refers to peripheral nerve blocks as
well as all NEUraXIaL aNEStHESIa, including EPIDUraL aNEStHESIa
and SPINaL aNEStHESIa.

remedial action: Actions taken to aid an individual including education, training, and/or reassignment to a task
appropriate to their knowledge and skill level.

restricted area: A designated space that can only be
accessed through a SEMI-rEStrICtED arEa to achieve a high
level of asepsis control. Traffic in the rEStrICtED arEa is limited to authorized personnel and patients, and personnel are
required to wear surgical attire and cover head and facial
hair. Masks are required where open sterile supplies or
scrubbed persons may be located.

Safety huddles: A short (5-15 minutes), stand-up meeting
involving the entire care team, led by senior leaders in a
non-judgmental environment at the same time each workday, to give the team a way to actively manage safety and
quality, including review of specific patient safety issues and
review of the care of patients who may be at higher risk for
an adverse outcome during or after a medical and/or surgical procedure.

Semi-restricted area: Peripheral support areas surrounding the rEStrICtED arEa of a surgical area, including storage
areas for clean and sterile supplies, sterile processing
rooms, work areas for storage and processing of
instruments, scrub sink areas, corridors leading to the
rEStrICtED arEa, and pump rooms.

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Smart infusion pump/smart infusion pump technology:
An infusion pump with integral computer software (see
DOSE ErrOr-rEDUCtION SyStEMS) that is, at a minimum, capable
of: 1) maintaining a drug library of standard drug concentrations, which when enabled, is used to support dose calculations and alert the user to incorrect orders, calculation
errors, or programming errors that would result in significant over- and under-delivery of a drug, electrolyte, or other
fluid; and 2) capturing administrative infusion data in a
systematic, objective manner to support improvement in
medication use. If the programmed dose is outside the
preset limits, the pump alerts clinicians and can either
require confirmation before beginning delivery (SOFt LIMIt)
or not allow delivery (HarD LIMIt).

Soft limit/soft stop (within drug library): A medication or
fluid-specific limit that can be overridden by a practitioner.
These upper (maximum) and lower (minimum) limits advise
the user that the specified infusion is about to be infused
outside facility-established parameters (e.g., common
dosage range).

look-alike drug names with recommended taLL MaN LEttErcan be found at: www.ismp.org/node/136.

INg

time-out: A formal process of active communication
among all team members involved in a medical and/or surgical procedure, by which, immediately prior to the procedure, all team members pause to review a standardized
checklist to confirm key aspects of the procedure, such as
verification of the patient, the procedure being performed,
procedure laterality, medications to be administered, and a
patient monitoring and rescue plan.

trigger(s): Critical indicators (e.g., laboratory values,
patient symptoms, use of antidotes for medications administered) that alert practitioners to the need for evaluation of
a potential adverse event.

Spinal anesthesia: A technique of managing pain in the
lower part of the body by the injection of an opioid and/or
anesthetic into the spinal canal, usually in the lumbar
region, to interrupt conduction of nerve impulses without
the loss of consciousness.

Surgical safety checklist: A tool similar to that created by
the World Health Organization (WHO) designed to improve
the safety of medical and/or surgical procedures by bringing together the whole procedural team (surgeons,
aNEStHESIa PrOVIDErS, aNEStHESIa PErSONNEL, and nurses) to
perform key safety checks during vital phases of perioperative care: prior to the induction of anesthesia (“sign
in”), prior to skin incision (“tIME-OUt”), and before the team
leaves the OPEratINg rOOM.

System design/redesign: Refers to the design/redesign of
processes, procedures, equipment, interfaces, overall
structure, and the environment or conditions under which
staff work, for the purpose of satisfying specific requirements, such as patient safety. The design of a system
dictates how reliable it is in terms of satisfying specific
requirements. 

tall man lettering: Refers to a method of differentiating
the appearance of similar drug names known to be confused with one another by using bolded, uppercase letters
to draw attention to a small group of unique letter characters that are different in each of the drug names. A list of

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About the Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) is the only 501c (3) nonprofit organization devoted entirely to preventing
medication errors. During its more than 25-year history, ISMP has helped make a difference in the lives of millions of
patients and the healthcare professionals who care for them.

ISMP is known and respected as the gold standard for medication safety information. It also has served as a vital force for
progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and
drug labeling and packaging.

Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and
offers a wide range of unique educational programs, tools, and guidelines.

In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world. The
affiliation allows both organizations to work more closely together for the benefit of providers, patient advocates, governments, and most importantly, patients.

From the affiliation, a new Patient Safety Organization took form: ECRI and the Institute for Safe Medication Practices PSO.
The launch of the new PSO created a single source for safety that harnesses the unprecedented expertise of each organization. Together, ISMP and ECRI bring up-to-date information and real-time guidance to assure healthcare leaders across
the continuum of care that they are making the best decisions to keep patients safe.

As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Learn more at
www.ismp.org.

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Endorsing Organizations

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