• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Medication Storage

  • Medication storage areas are clean, neat, and well organized.

  • External use medications are stored separately from internal use medications.

  • No food products or lab specimens are stored near drugs.

  • Narcotics are in a secure storage area.

  • Narcotic cabinet is double locked.

  • Crash cart is locked.

  • Crash cart locks are stored in a locked cabinet.

  • Refrigerated Medications are stored in a refrigerator at 36 - 46 degrees F.

  • Medication refrigerator is used for medications only.

  • Medications are secured appropriately during and outside of hours of operation.

  • There are no outdated medications.

  • Anesthesia carts are locked when not in use.

  • Medication waste is disposed of according to policy.

  • No pre-drawn doses of medication or pre-drawn syringes are present.

Medication labeling

  • All medications are labeled properly, preferably in the original manufacturer's package.

  • Opened multidose vials are labeled with the date the vial will expire (28 days after first use).


  • Tamper proof prescription pads are used.

  • Prescription pads are stored in locked cabinets away from patient access.

  • Pre-signed and/or post dated prescription pads are not used.


  • Refrigerator temperature log is complete and up to date.

  • Daily narcotic counts and balances agree.

  • Narcotic counts are done at the beginning and end of the shift.

  • Narcotic counts have 2 licensed nurse signatures, including waste of controlled medications.

  • Medication review is done in Admitting.

  • Medication reconciliation is done in DWA.

  • A file of recalled medications is maintained.

  • Adverse drug reactions are recorded on an Incident form and reviewed by the pharmacy consultant.

  • An Incident Report is completed in the event of a medication error, and reviewed by the pharmacy consultant.


  • Current drug references are available to staff e.g. Nurse Drug Reference, online drug reference.

  • DEA permits are available and current.


  • Discussion/recommendations:

  • Manager is emailed the monthly report, include name

  • Audit done by:

  • Pharmacist review

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