36C25618R0078-018.docx
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- Houma CBOC replaces VA256-16-R-0015
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- 36C25618R0078
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36C25618R0078 ATT D12 VA Form 10-0053.docx
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MEDICATION INSPECTION FORM FOR WARDS AND CLINICS
| WARD/CLINIC INSPECTED |
| DATE |
REVIEW SUBJECT
CHECKED
& OK
| PROBLEM NOTED |
| COMMENTS/ACTION TAKEN |
(for additional comments, use last page)
A. Ward/Clinic Area
1. Medication cart and medication room are properly secured.
2. The storage area is clean (free of visible dust, spilled liquids, etc.).
3. Arrangement and general neatness is satisfactory.
4. Shelf labels, when present, are readable (not soiled, marked or defaced).
5. Metric and apothecary conversion sheet is posted or available electronically.
6. Poison control center telephone number is posted or available electronically.
7. Antidote chart is posted or available electronically.
B. Medications
8. Medications are stored under conditions suitable for product stability. (e.g., appropriate temperature, light, etc)
9. All medications are securely stored in accordance with medical center policy and medications are not left unattended outside the med room.
10. Internal medications are separated from external medications.
11. Patient medications are separated from ward stock and stored in accordance with medical center policy.
12. Non-medication items are separated from medications.
13. Medications are stocked with earliest dated items placed forward in the storage location.
14. All medications are within their expiration date.
15. Only approved medications are stocked/stored (on the approved ward stock list, no samples, restricted or non-formulary drugs).
16. Concentrated electrolytes (e.g, potassium chloride, sodium chloride > 0.9%, potassium phosphate) are not present. (Exception: areas that have been approved to store concentrated electrolytes. In these areas, precautions are in place in accordance with medical center policy to prevent inadvertent administration.)
17. Medication quantities are within the approved stock levels.
18. Medications are properly labeled (this includes any medication or solution transferred from the original packaging to another container)
19. Medication labels are readable (not soiled, marked or defaced).
20. Opened multi-dose vials are dated and stored in accordance with Medical Center policy.
21. Medications and parenteral fluids show no signs of obvious deterioration.
22. All expired, damaged, and/or contaminated medications are segregated until they are removed from the storage area.
23. Investigational medications are properly labeled and stored in accordance with medical center policy.
ATTACHMENT D12 - HOUMA
VA FORM OCT 2007
10-0053 Page 1 of 2
| WARD/CLINIC INSPECTED |
| DATE |
REVIEW SUBJECT
CHECKED
& OK
| PROBLEM NOTED |
| COMMENTS/ACTION TAKEN |
(for additional comments, use last page)
24. Look alike/sound alike medications are labeled and/or stored in accordance with medical center policy.
25. High Alert medications are labeled and/or stored in accordance with medical center policy.
26. Medications are available in the most ready to administer forms available from the manufacturer.
27. Controlled medications (CII through CV) are secured in accordance with medical center policy.
28. No prescription pads are in unsecured, open areas.
C. Refrigerator
29. The refrigerator contains only medications and admixtures requiring storage at reduced temperatures (i.e. no food, lab specimens, etc. are present).
30. The refrigerator is clean (free of visible dust, spilled liquids, etc.).
31. The refrigerator is locked if not in med room.
32. If the refrigerator contains controlled substances, it is locked or the controlled substances are locked within a secure, non-removable box within the refrigerator.
33. Refrigerator temperature is monitored in accordance with Medical Center policy and the log is up to date.
34. Refrigerator temperature reading:
35. The temperature reading is between 36 and 46 degrees Fahrenheit.
D. Crash Carts
36. The crash cart(s) is in date.
37. The crash cart lock(s) are intact and secured to prevent tampering (i.e the tab pulled all the way through to the end).
38. Please list crash cart #(s), lock #s, and expiration dates(s) below.
Crash cart #: Crash cart lock #: exp. date: Crash cart #: Crash cart lock #: exp. date:
E. Facility-Specific Requirements
F. Additional Comments (indicate review subject and number)
| Nursing Reviewer |
| Pharmacy Reviewer |
| Print Name: |
| Print Name: |
| Signature: |
| Signature: |
| Date: |
| Date: |
VA FORM OCT 2007
10-0053
Original Copy retained in Pharmacy. Copies of completed form to Nursing Service and Chief of Staff
File details come from the government source that posted it. Updated .