• Document No.

  • Audit Title

  • Conducted on

  • Prepared by

Drug Control and Storage

  • Single use vials discarded after one use.

  • All drugs on unit are locked and secure (check entire unit and carts for unsecured medications).

  • No food or any unauthorized medication or products is in the refrigerator or Pyxis.

  • Medication area or room is clean, neat, and well organized.

  • Drugs are NOT left unsecured on top of carts or counters or in pneumatic tubes

  • Medications in locked carts are properly labeled with patient identifier (check 2 cart)

  • Medications to be returned to pharmacy are in the authorized location.

  • Medication area is HIPAA compliant

Controlled Drugs

  • Discrepancies are cleared off of ADC per shift

Emergency medications

  • Crash cart locked and in date with next expiring date posted. Add crash cart number.

  • Crash Cart Numbers:

  • Paralytic agents (rocuronium and succinylcholine) are present, if appropriate)<br><br>

  • Crash cart red lock is pulled securely to prevent unauthorized access.

  • Emergency kits, if available, or in date

  • Emergency kit numbers:


  • Pyxis medications are in date (check Pyxis report and the 3 samples)<br>

  • Pyxis refrigerators are clean, organized, and free of frost or ice.

  • Pyxis med station should be neat, clean, and functioning properly.

Pharmacy Tasks

  • Reconcile patient specific meds in tower and refrigerator

  • Check for any short dated meds to remove or rotate

  • Clean keyboard and tops to cabinets with disinfectant

Technician or designee completing inspection

  • Date and time of inspections

  • Technician or designee

  • Add media

Nursing Director or designee

  • Forwarded to nursing director or designee

Pharmacy Director or designee

  • Reviewed

  • Select date

  • Followup:

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