MMH TJC - RX - Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

MEDICATION MANAGEMENT

• Medication rooms are clean and uncluttered.

  Yes

  No

  N/A

• Laminar flow hood is used for IV admixture when appropriate.

  Yes

  No

  N/A

• Visual inspection of medication containers: No Issues.

  Yes

  No

  N/A

• Area free of distractions.

  Yes

  No

  N/A

• Medication is appropriately labeled.<br> * Expiration dates, directions, etc..

  Yes

  No

  N/A

• All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  Yes

  No

  N/A

• Controlled substances stored to prevent diversion.

  Yes

  No

  N/A

• Medications stored appropriately to maintain stability.

  Yes

  No

  N/A

• Medications, formula, & solutions not expired beyond expiration date.

  Yes

  No

  N/A

• Opened multi-dose vials dated and initialed. Not expired.

  Yes

  No

  N/A

• Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full

  Yes

  No

  N/A

• Syringes are labeled when in use.

  Yes

  No

  N/A

• Medication refrigerator: Only contain medications for current patients.

  Yes

  No

  N/A

• Breast Milk Refrigerators: Only contain milk for current patients.

  Yes

  No

  N/A

• Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside.

  Yes

  No

  N/A

• Medication Carts: Doors and drawers are locked.

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

• Have a space designated for the team to conduct interviews and file reviews.

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

• Any additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• SURVEYORS SIGNATURE

  Sign