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CRITERIA
MEDICATION STORAGE
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Narcotic and controlled medications are stored in a doublelocked cabinet
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External products is stored separately from internal and injectable medications
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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
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The humidity of all rooms containing medications is monitored daily
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Medication refrigerator is kept within 2°C to 8°C
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The humidity of the medication room is maintained at 35 to 60 RH
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Multidose vials are labelled with opening and expiry dates
HIGH ALERT MEDICATION & LOOK ALIKE SOUND ALIKE MEDICATIONS
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LASA medications are stored separate from one another or in nonalphabetical order. Storage on different shelves is preferable whenever possible
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HAMs are stored with the red “High Alert Medication” auxiliary label on each floor stock cassette
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Nurse label patient specific drawn up HAMs for injection or oral/enteral feeding solution by a “High Alert Medication” label
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Tallman lettering is used in labeling LASA medication, to distinguish sound alike medications
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Two nurses perform independent doublecheck before the administration of LASA and HAM medications with complete documentation of the process in Epic
MEDICATION PREPARATION AND ADMINISTRATION
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The nurse perform hand hygiene prior to preparation and after administration
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Medication is prepared inside the medication room/designated area
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Medication is brought on a tray to patient’s bedside
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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
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The nurse scans the patient ID band and medication barcode label
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The nurse monitor patient’s response to medication and document in the Epic
KNOWLEDGE ASSESSMENT
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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
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The nurse is able to verbalize: The process of telephone order
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The nurse is able to verbalize: The process of verbal order
