• 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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.