The 8 Most Commonly Cited Pharmacy Deficiencies in ASC Surveys

Medication-related findings often repeat because they sit at the intersection of policy, staff practice, and documentation. These are eight areas every ASC should be ready to explain and demonstrate.

Medication labeling gaps

Any medication or solution that is not immediately administered should be labeled according to facility policy and applicable standards. Labels should include the medication name, strength, amount when not apparent, diluent and volume when applicable, expiration date or time, and preparer identity. Surveyors may look at syringes, cups, basins, anesthesia carts, sterile fields, and medication preparation areas.

Multi-dose vial practices

Multi-dose vials should not be kept in immediate patient treatment areas such as ORs, procedure rooms, or anesthesia carts. Once a multi-dose vial enters a patient care area, the facility should treat it as single-patient use and not return it to common storage.

Controlled substance records and reconciliation

Controlled substance records should reconcile to the anesthesia or medication administration record, with documented waste, prompt discrepancy investigation, and the required inventory records maintained. Some states and facilities also expect perpetual inventory and periodic reconciliation. Unwitnessed or poorly documented waste is a common controlled substance finding.

Temperature monitoring records

Temperature logs should be completed according to facility policy and storage requirements, with a documented response to any excursion that records who was notified and what action was taken. Records should reflect real monitoring rather than entries made after the fact.

Expired medications and emergency readiness

Expired medications on the shelf or in the emergency cart are a frequent and avoidable finding. Emergency readiness also means the team can actually use what is stocked, including knowing where the malignant hyperthermia medications are and how to prepare them under pressure, not simply that the cart exists.

Policies and procedures that do not match practice

Surveyors often compare the written policy to staff answers and actual practice. If the policy says one thing, the nurse describes another, and the chart shows something different, the center has a problem. Strong policies and procedures should be current, realistic, and teachable.

Inconsistent allergy documentation

Allergy documentation should include the specific reaction type, not just the allergen name, and should be consistent across intake, nursing, anesthesia, and procedure documentation. No known drug allergies, or NKDA, should be affirmatively documented when applicable.

A missing or weak QAPI project

ASCs need a meaningful quality improvement process, and medication management is one of the most practical pharmacist-led QAPI topics. Many centers have a project on paper but lack clear methodology, data, follow-up, or governing-body-ready conclusions. A strong medication-related QAPI project has a defined method, real data, and conclusions ready for the governing body. This kind of follow-through is central to our pharmacy program.

Bringing it together

None of these are unusual or exotic. They tend to come from a pharmacy program that depends on one person’s memory rather than a repeatable process. Requirements vary by state and accreditor, so confirm the specifics with your own accrediting body and board of pharmacy.