patients and employees from harm, according to Ms. Geier. She says
they will also confirm that active shooter drills are conducted, and
there's limited access for approved employees only into the clinical
care area of the facility.
• Hand hygiene. Surveyors will watch employees' hand hygiene
practices without letting them know they're being observed. Are
they washing their hands after removing gloves? Are staff members
observing their colleagues' practices and reporting non-compliance
issues? Do they have convenient access to alcohol-based hand rub
dispensers? Do they know of places where additional dispensers
should be located?
• Medication management. Be ready for questions regarding your
medication procurement, dispensing and security policies, says
Kathryn Thompson, MSN, RN, CNOR, senior manager of clinical serv-
ices and operations at Emory Clinic in Atlanta, Ga. She says surveyors
will want to know what you're doing to ensure the right medication
and right dose is administered to the right person by the right route at
the right time. Also differentiate medications with similar-sounding or
similar-looking names (Tall Man lettering is a good option) and store
them in clearly marked, non-adjacent drawers to avoid confusion.
Ms. Thompson, who led efforts to prepare for an accreditation sur-
vey at Northside Hospital in Atlanta, her former place of employment,
suggests having a policy in place that accounts for all medications
that are stored and used, how leftover amounts are disposed of and a
customized method for ensuring high-alert medications are tracked
and stored in a secured location. She says surveyors also check to
make sure crash cart medications are fully stocked and up to date,
and ask for justification of overstocked medications. Keeping an
abundant supply of drugs that are in constant shortage is a valid rea-
son, for example.
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