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ACCOUNTABILITY
FIVE MOST COMMON FACILITY INSPECTION ISSUES
As part of its facility inspection process, the
College and the Accreditation Committee
monitor the types of deficiencies that are most
commonly identified during an inspection.
This data is used to identify risk areas where
facility directors and veterinarians working
from a facility can direct their attention to
ensure adherence to the Minimum Standards
for Vet erinary Facilities in Ontario (MSVFO).
The College also uses this data to direct
resources to assist veterinarians in meeting
standards.
The most commonly identified deficiencies
over the past year include:
Absent Controlled Drug Log
The maintenance of an accurate controlled
substances log is mandated, not only by the
MSVFO, but also by the Controlled Drugs
and Substances Act and the Veterinarians
Act. The controlled drug log must contain
an accurate accounting of the addition to
inventory and dispensing of all controlled
substances managed by a facility. A sample
controlled substances log is available on the
College website at www.cvo.org/SampleControlled-Substances-Log.
Further information regarding management of
controlled substances, including the keeping
of a log, can be found in the Professional
Practice Standard: Management and Disposal
of Controlled Substances and the Guide to
the Standard. Both documents are on the
College website at www.cvo.org/ VeterinaryPrescribing-and-Dispensing.
No evidence of
weekly Controlled
drug audits
To further assist with the
accuracy of a controlled
drug log and to increase
the vigilance around
controlled substances
management, most
facilities are required
to demonstrate that a controlled drug
audit is carried out on a weekly basis. For
those facility categories for which a regular
controlled drug audit is not mandated by
the MSVFO, a regular audit is strongly
recommended. Tips for carrying out a
Controlled Drug Audit can be found on the
College website at www.cvo.org/ Tips-forconducting-audits.
Further information regarding the
requirements and process associated with
an audit can be found in the Professional
Practice Standard: Management and
Disposal of Controlled Substances and the
Guide to the Standard. Both documents
are on the College website at www.cvo.org/
Veterinary-Prescribing-and-Dispensing.
Mixing of Expired Drugs and
Unexpired Drugs
During facility inspections, inspectors
frequently encounter expired drugs that
are kept amongst unexpired drugs. Such a
practice can increase the risk of inadvertently
dispensing an expired drug. Expired drugs
must be kept separate from unexpired
drugs and disposed of in accordance with
the Food and Drug Act and the Controlled
Drugs and Substances Act or returned to the
manufacturer for disposal. Before destroying
any controlled drug, veterinarians must
contact Health Canada, Office of Controlled
Substances to request the form that must be
submitted to obtain permission to destroy
controlled drugs.
X-ray Sources Not Registered with
the Ministry of Labour
Each x-ray source in an accredited facility
must be inspected and registered with the
Ministry of Labour. Registration numbers for
each x-ray source must be made available
during a facility accreditation inspection.
More information regarding radiation safety
can be found on the College website at www.
cvo.org/Radiation-Safety.
Absent Surgical and Anesthesia
Logs
It is a requirement under the MSVFO that
Anesthesia and Surgery logs be maintained in
accredited facilities. The information required
for these two logs need not be separate but
can be combined into a single log. Logs can
be maintained electronically.
The details of the requirements for the
Anesthesia and Surgery logs are on the
College website at www.cvo.org/SampleInspection-Forms.
The College recommends that directors
of facilities, particularly for those facilities
undergoing inspection, familiarize themselves
with the requirements for their facility type(s)
as set out in the MSVFO (available online
on the College’s website at www.cvo.org/
MSVFO). Sample inspection forms for
specific facility categories are also available
on the College website (www.cvo.org/SampleInspection-Forms).
Summer 2015 / 7