Location:	PH - Behavioral Health Unit 23
Status:	Completed
Scheduled Date:	2019-08-28
Due Date:	2019-09-27
Performed Date:	2019-09-25
Assigned To:
Performed By:	Wong, Wanda
Emails:
Notes:

Section	Question	Status	Notes
Medication Security	Medication room 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	N/A
Medication Security	All procedure carts/trays/boxes with meds are locked	N/A
Medication Security	Malignant Hyperthermia cart is locked/secured	N/A
Medication Security	Rx pads/syringes/needles/IV's secure	Compliant
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)	Compliant
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	40 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	N/A
Drug Storage	IV/Irrig. Warmer is in range (less than 104 deg. F). Enter the temperature in the notes section.	N/A
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	Compliant
Drug Storage	Internals separated from externals	Non-Compliant	Stored in patient cassette with oral meds: nystatin powder, polysporin ointment, clotrimazole cream, clobetasol cream
Drug Storage	All controlled substances secure	Compliant
Drug Storage	Paralytics are segregated and marked with caution label	N/A
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	N/A
Drug Storage	All IV's out of overwrap are dated appropriately	N/A
Drug Storage	Plain IV's (from Supply pyxis) are not expired	N/A
Drug Storage	No expired meds & IV's present	Non-Compliant	Patient’s own Bio True Solution expired 11/2017
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	Compliant
Drug Storage	No samples or herbal meds present	Compliant
Drug Storage	Any patient own meds are verified by Pharmacy	Non-Compliant	Bio True Solution not verified—expired 11-2017
Drug Storage	All meds & IV's are properly labeled	Non-Compliant	Humalog labeled “Alert—concentrated electrolyte, not for injection”
Drug Storage	Only authorized stock is present and within par levels	Compliant
General Issues	Poison Control, MSDS 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

Reviewer Email:	reesemf@sutterhealth.org
Notes: