Scheduled Inspection for VN - 4 OR Inspection
Location: VN - 4 OR
Status: Completed
Scheduled Date: 2019-08-21
Due Date: 2019-09-20
Performed Date: 2019-09-18
Assigned To:
Performed By: Wong, Wanda
Emails:
Notes: Mini spike dispensing pins expired 8/2017–see photo. Bottle of Lorann Oils Raspberry flavor in pink infant procedure cart in room 4370 (anesthesia equipment room) has no expiration date, and looks to be very old. Company website says flavors should last “several years” but there is no indication of how old this bottle is.

Section Question Status Notes
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 Non-Compliant Critical care cart not locked. HMS cart not locked.
Medication Security Malignant Hyperthermia cart is locked/secured Compliant Refrigerator 41.5 deg F
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
Infection Control Immediate use CSPs are labeled correctly and not expired N/A
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
Infection Control Dept has proper disposal equipment (drug/chemo/sharps) Non-Compliant OR6, OR7 and OR8 blue and white bins not on raiser, see 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 38.5 and 39 deg F
Drug Storage Freezer temperature in range(below 0 deg. F). Enter the temperature in the notes section. N/A
Drug Storage Freezer does not need defrosting or cleaning N/A
Drug Storage Contrast/IV/Irrig. in warmer are dated and in date Non-Compliant Dates on solutions not legible—see photo. LR 1 liter in warmer undated.
Drug Storage IV/Irrig. Warmer is in range (less than 104 deg. F). Enter the temperature in the notes section. Compliant 103, 100, 102, 100, 100, 100, 100, 100, 101, 100 deg F
Drug Storage Contrast Warmer is in range (less than 98.6 deg. F). Enter the temperature in the notes section. N/A
Drug Storage Refrigerator/Warmer temp logs are complete N/A Aeroscout
Drug Storage Internals separated from externals Compliant
Drug Storage All controlled substances secure Compliant
Drug Storage Paralytics are segregated and marked with caution label Non-Compliant Vecuronium missing caution label—see photo. Cisatracurium missing caution labels.
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 Non-Compliant LR (2 bags) out of overwrap in solution warmer, hooked up to IV tubing, were undated.
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 N/A
Drug Storage All meds & IV's are properly labeled Non-Compliant Vasostrict labeled with 2different expiration dates—see photo. Arzol missing RCRA sticker.
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. N/A
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 N/A
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) N/A

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Reviewer Email: masterm@sutterhealth.org
Notes: