Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Medication Prepackaging Competency

  • Demonstrate the understanding that the sign off on the prepacking log is a complete signature.

  • Demonstrate how to print off prepacking record.

  • Demonstrate how to avoid mislabeling of drugs.

  • Demonstrate how to properly clean the prepackager (must utilize disposible gloves).

  • Demonstrate how to enter new medication information into the master library file.

  • Demonstrate how to change packaging tape and plastic.

  • Demonstrate knowledge of the "Pre-packaging quantity notebook" to determine quantity to package.

Refrigerator Monitor-Thermometer Competency

  • Demontrate correct battery installation.

  • Demonstrate competency in attaching external sensor into side jacket.

  • Demonstrate competency using MODE button.

  • Demonstrate completency in using MEMORY CLEAR button.

  • Demonstrates competency in setting Minimum or Maximum temperature limits.

  • Demonstrates competency in displaying temperature readins in Fahrenheit or Celsius.

  • Demonstrates competency to temporarily silence alarm.

Pharmacy Balance Competency

  • Understands recommended 2 hour warm-up period before use.

  • Demonstrates competency in leveling balance by plcement of "bubble" in center black ring.

  • Demonstrates competency in calibration of balance using 1000 gram weight (do not touch with hands).

  • Demonstrates competency in taring to zero weighing container.

  • Demonstrates competency in changing units from "mg" to "grams."

  • Understand correct documenttion of balance leveling and calibration in compounding log.

  • Demonostrates competency in clearning and returning balance to storage area.

On-Q Elastomatic Pump and PCA Filling/Priming Competency

  • Demonstrates understanding of pump components.

  • Demostrates awareness of various sizes of pumps.

  • Demonstrates critical sites of pumps for contamination.

  • Demonstrates filling procedure for various pumps and aware of overfill allowance.

  • Demonstrates correct manipulation of clamps.

  • Demonstrates proper labeling of pumps (2 labels) and expiration dating of various pumps.

  • Demonstates correct placement of tamper-resistant seal on blue cap.

  • Ware that 100ml (non-cardiovascular case) requires outpatient labeling: "use as directed" and "dispose?" attached.

  • Demonstates competency in filling/labeling of PCAs.

Expiration Audit Reports and Outdating Process

  • Understands times of expiration reports printing.

  • Demonstrates competency in highlighting and expiring drugs within that month.

  • Demonstrates competency in moving vancomycin 1 gm pre-mixed bags, brfovana inhalation packets, and pulmicort inhalation suspensions according to their high usage daily reports.

  • Demonstrates competency in moving any narcotic PCAs to high usage areas (recovery/PACU).

  • Demonstrates competency in bringing back expired narcotics to pharmacy and running report for pharmacist to check for accuracy.

  • Demonstrates competency in bringing back expired meds and writing up correctly on drug expiration log as well as disposing in correct bin.

  • Demonstrates competency in understanding that montly expiration need to be pulled through the following month and tagged with stickers for the following 3 months (ex: if it is may, all of June should be pulled and July, August, and September should be tagged).

  • Understands that tagged stickers should not be placed over bar-coded labels for ordering purposes.

Crash Cart Tray Replacement Competency

  • Understands hospital departments involved in crash cart process

  • Upon delivery of used medication trays to pharmacy, the technician checks to make sure there is a patient name for charging purposes.

  • Understands the specific medications trays used in adult and pediatric carts.

  • Demonstrates competency in completion of medication charge forms.

  • Demonstrates competency in refilling trays back to par with any medications that were used and accurately filling in earliest drug to expire in the log book.

  • Demonstates competency in utilizing crash cart notebooks (the drug expiration log book and cart placement log book).

  • Demonstrates competency in obtaining red numbered lock and completion of red crash cart label.

  • Understands pharmacist must DOUBLE CHECK tray replacement prior to red lock placement on the cart.

  • Understnads cart location placement of 2 white or green security locks for post code use.

  • Undersnads which department (CSPD) to contact for cart pick up and storage.

Cardiac Cart Cleaning/Filling Competency

  • Understands OR notification process to pick up/drop off used cardiac cart and what location.

  • Understands used cardiac cart refill priority upon returning to pharmacy.

  • Demonstrates review and removal of used cardiac trays.

  • Demonstrates proper completion of medication charge forms for all trays used.

  • Demonstrates proper cleaning of empty cart with germicidal disposable wipes.

  • Demonstrates matching number systme of replacement trays for the cardiac cart.

  • Demonostrates ALL replacement trays are reviewed for expiration dating and proper placement of "earliest Item to Expire" sticker is placed on top right hand corner.

  • Demonstrates proper placement of "Kit Filled By" sticker in top right hand corner.

  • Demonstrates use of "Heart Cart Ready for Checking" sign for pharmacist notification as well as announcing to a pharmacist that there is a completed cart.

Bar-coding Care Manager Competency

  • Demonstrates competency in printing bar-code labels.

  • Verifies correct bar-code is selected (checks NDC).

  • Bar-codes medication correctly to allow bar-code to be scanned.

  • Correctly completed bar-coding log for medication bar-coded.

  • Demonstrates competency in verifying medication bar-code on test patient.

  • Demonstrates competency in saving a bar-code.

  • Correctly uses Meds Manager "Facility Inventory" to determin Medication (NDC) exists in Meds Manager before checking CareManager to save/print.

Sign Off

  • On site representative

  • Auditor's signature

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