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  • Narcotic and controlled medications are stored in a doublelocked cabinet

  • External products is stored separately from internal and injectable medications

  • The temperature of all refrigerators and rooms containing medications are monitored daily and, in the event, that an inappropriate temperature appears: the reason alarm change in temperature and action to correct the malfunction is taken and documented

  • The humidity of all rooms containing medications is monitored daily

  • Medication refrigerator is kept within 2°C to 8°C

  • The humidity of the medication room is maintained at 35 to 60 RH

  • Multidose vials are labelled with opening and expiry dates


  • LASA medications are stored separate from one another or in nonalphabetical order. Storage on different shelves is preferable whenever possible

  • HAMs are stored with the red “High Alert Medication” auxiliary label on each floor stock cassette

  • Nurse label patient specific drawn up HAMs for injection or oral/enteral feeding solution by a “High Alert Medication” label

  • Tallman lettering is used in labeling LASA medication, to distinguish sound alike medications

  • Two nurses perform independent doublecheck before the administration of LASA and HAM medications with complete documentation of the process in Epic


  • The nurse perform hand hygiene prior to preparation and after administration

  • Medication is prepared inside the medication room/designated area

  • Medication is brought on a tray to patient’s bedside

  • Independent doublecheck is done by 2 nurses including electronic dual signature in Epic and manual documentation on the label with the name of 2 nurses, date & time, and signature

  • The nurse scans the patient ID band and medication barcode label

  • The nurse monitor patient’s response to medication and document in the Epic


  • The nurse is able to verbalize: Patient safety events related to HAM is to be reported within 24 hours of occurrence under the specified medication error type on DATIX

  • The nurse is able to verbalize: The process of telephone order

  • The nurse is able to verbalize: The process of verbal order

Reference: CPP 143469 Medication Management General, CPP 143528 Storage of Medications and Anesthetic Agents, CPP 1431201 High Alert Medications, CPP 1432203 Look Alike SoundAlike Medication, CBAHI Standards 3rd edition: MM 1MM 41, JCI standards 7th edition: MMU 1MMU 7, IPSG 3, IPSG 3.1

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