| Medication Security |
Medication room door and/or cabinet is locked |
Compliant |
|
| Medication Security |
All medications are in secure area including oral contrast |
Compliant |
|
| Medication Security |
Drug refrigerator is in locked area or has lock |
Compliant |
|
| Medication Security |
Crash cart is secured with locked seals |
Compliant |
|
| Medication Security |
All procedure carts/trays/boxes with meds are locked |
Compliant |
|
| Medication Security |
Malignant Hyperthermia cart is locked/secured |
N/A |
Na |
| Medication Security |
Rx pads/syringes/needles/IV's secure |
Compliant |
|
| Infection Control |
Alaris Infusion Pumps are labeled correctly as clean using clean sticker. Pumps in use or used should not have clean sticker. |
N/A |
Na |
| Infection Control |
Immediate use CSPs are labeled correctly and not expired |
N/A |
Na |
| Infection Control |
No food/Lab specimens in refrigerator |
Compliant |
|
| Infection Control |
Drug storage area is neat/clean/organized |
Compliant |
|
| Infection Control |
No open single dose vials |
Compliant |
|
| Infection Control |
Reconstituted vials are dated and labeled properly |
N/A |
Na |
| Infection Control |
Dept has proper disposal equipment (drug/chemo/sharps) |
Non-Compliant |
Pharmacy blue and white bin on floor of exam room 3, not on raiser, also lid not securedsee photo |
| Drug Storage |
All refrigerated meds in refrigerator |
Compliant |
|
| Drug Storage |
Temperature of Refrigerator in range (36-46 deg. F). Enter the temperature in the notes section. |
Compliant |
42.5 deg F |
| Drug Storage |
Freezer temperature in range(below 0 deg. F). Enter the temperature in the notes section. |
N/A |
Na |
| Drug Storage |
Freezer does not need defrosting or cleaning |
N/A |
Na |
| Drug Storage |
Contrast/IV/Irrig. in warmer are dated and in date |
N/A |
Na |
| Drug Storage |
IV/Irrig. Warmer is in range (less than 104 deg. F). Enter the temperature in the notes section. |
Compliant |
Na |
| Drug Storage |
Contrast Warmer is in range (less than 98.6 deg. F). Enter the temperature in the notes section. |
Compliant |
|
| Drug Storage |
Refrigerator/Warmer temp logs are complete |
Compliant |
|
| Drug Storage |
Internals separated from externals |
Compliant |
|
| Drug Storage |
All controlled substances secure |
Compliant |
|
| Drug Storage |
Paralytics are segregated and marked with caution label |
Compliant |
|
| Drug Storage |
No concentrated electrolytes present |
Compliant |
|
| Drug Storage |
All emergency drugs and IV's (crash cart, Malig. Hypth.cart,etc) are in date and contents posted on outside |
Compliant |
|
| Drug Storage |
All IV's out of overwrap are dated appropriately |
Compliant |
|
| Drug Storage |
Plain IV's (from Supply pyxis) are not expired |
Compliant |
|
| Drug Storage |
No expired meds & IV's present |
Compliant |
|
| Drug Storage |
All short dated items (Surestep, Insulin, etc.) are dated and in date |
Compliant |
|
| Drug Storage |
No meds present for discharged patients or d/c'd orders (including refrigerator) |
Compliant |
|
| Drug Storage |
No samples or herbal meds present |
Compliant |
|
| Drug Storage |
Patient's own meds are verified and labeled by Pharmacy |
Compliant |
|
| Drug Storage |
All meds & IV's are properly labeled |
Compliant |
|
| Drug Storage |
Only authorized stock is present and within par levels |
Compliant |
|
| Drug Storage |
Medication drawn up into a syringe by RN or Anesthesia is labeled. |
Compliant |
|
| General Issues |
Poison Control, SDS phone #'s posted |
Compliant |
|
| General Issues |
No pt identification labels/info in trash |
Compliant |
|
| General Issues |
If chemo used, chemo spill kit present |
Compliant |
|
| General Issues |
White boards / Status Boards have only patient last name |
Compliant |
|
| General Issues |
Computer EPIC charts are logged out and not left open unattended in common area |
Compliant |
|
| General Issues |
Alaris Infusion Pumps - guardrails in use for IV fluids, IV drips or IVPB medications (no basic infusion) |
Compliant |
|
