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