In two hospital surveys this month (12/3 and 12/12), I issued findings for syringes without time-stamped labels and IV lines not traced from pump to patient, plus missing documentation of prep times to meet the revised USP 797 immediate-use limits. Are your CRNA teams tightening cart-check protocols and implementing time labels before Q1, or are you seeing different interpretations on the floor?
We added time-stamp dot stickers to every cart and made “trace to the face” part of the pre-induction pause; the visual time on syringes cut our misses to near zero. For true stat cases, we slap the dot, draw up, and complete the prep-start field in the EMR right after wheels-in so the USP 797 clock is still clear. My labeler’s getting more reps than my laryngoscope lately.
We got dinged in November too, so we slapped a $12 self-inking time stamp on each cart and pre-printed syringe labels with “drawn” and “expire” boxes — made the USP 797 prep-time piece painless. For lines, we add a green clip to the traced primary and say “face to pump” during the pause — @willC78 your dot stickers are slick, but the clip’s been easier for float staff. One surveyor still wanted date plus military time on labels, , so we tweaked the stamp.