S02 - Attachment 17 - Medication Inspection Form for Wards and Clinics.pdf
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- Q201--10 Year Scottsbluff CBOC
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- 36C26322R0091
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Page 1 of 210-0053OCT 2007
VA FORM
REVIEW SUBJECT
COMMENTS/ACTION TAKEN
(for additional comments, use last page)
A. Ward/Clinic Area
CHECKED
& OK
MEDICATION INSPECTION FORM
FOR WARDS AND CLINICS
WARD/CLINIC INSPECTED
PROBLEM
NOTED
B. Medications
1. Medication cart and medication room are properly secured.
7. Antidote chart is posted or available electronically.
12. Non-medication items are separated from medications.
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.)
15. Only approved medications are stocked/stored (on the approved ward stock list, no samples, restricted or non-formulary drugs).
14. All medications are within their expiration date.
13. Medications are stocked with earliest dated items placed forward in the storage location.
11. Patient medications are separated from ward stock and stored in accordance with medical center policy.
10. Internal medications are separated from external medications.
9. All medications are securely stored in accordance with medical center policy and medications are not left unattended outside the med room.
8. Medications are stored under conditions suitable for product stability.
(e.g., appropriate temperature, light, etc)
6. Poison control center telephone number is posted or available electronically.
5. Metric and apothecary conversion sheet is posted or available electronically.
4. Shelf labels, when present, are readable (not soiled, marked or defaced).
3. Arrangement and general neatness is satisfactory.
2. The storage area is clean (free of visible dust, spilled liquids, etc.).
DATE
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.
Page 2 of 210-0053OCT 2007
VA FORM
REVIEW SUBJECT
COMMENTS/ACTION TAKEN
(for additional comments, use last page)
CHECKED
& OK
WARD/CLINIC INSPECTED
PROBLEM
NOTED
DATE
24. Look alike/sound alike medications are labeled and/or stored in accordance with medical center policy.
30. The refrigerator is clean (free of visible dust, spilled liquids, etc.).
29. The refrigerator contains only medications and admixtures requiring storage at reduced temperatures (i.e. no food, lab specimens, etc. are present).
28. No prescription pads are in unsecured, open areas.
27. Controlled medications (CII through CV) are secured in accordance with medical center policy.
26. Medications are available in the most ready to administer forms available from the manufacturer.
25. High Alert medications are labeled and/or stored in accordance with medical center policy.
C. Refrigerator
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 Print Name:
Signature:
Date:
Original Copy retained in Pharmacy. Copies of completed form to Nursing Service and Chief of Staff
Print Name:
Pharmacy Reviewer
Signature:
Date:
Meds by Mail Order Form vhahackappej Order form for new prescriptions covered under the Meds by Mail program.
D:20030909220852Z D:20050308083150- 07'00' Page of 10-0053 10 - 10 S H
OCT 2007
V. A. FORM JULY 19 98
VA FORM
REVIEW SUBJECT
COMMENTS/ACTION TAKEN
(for additional comments, use last page) A. Ward/Clinic Area
CHECKED
& OK
\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs
MEDICATION INSPECTION FORM
FOR WARDS AND CLINICS
PROBLEM
NOTED
B. Medications
1. Medication cart and medication room are properly secured.
7. Antidote chart is posted or available electronically.
12. Non-medication items are separated from medications.
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.)
15. Only approved medications are stocked/stored (on the approved ward stock list, no samples, restricted or non-formulary drugs).
14. All medications are within their expiration date.
13. Medications are stocked with earliest dated items placed forward in the storage location.
11. Patient medications are separated from ward stock and stored in accordance with medical center policy.
10. Internal medications are separated from external medications.
9. All medications are securely stored in accordance with medical center policy and medications are not left unattended outside the med room.
8. Medications are stored under conditions suitable for product stability.
(e.g., appropriate temperature, light, etc)
6. Poison control center telephone number is posted or available electronically.
5. Metric and apothecary conversion sheet is posted or available electronically.
4. Shelf labels, when present, are readable (not soiled, marked or defaced).
3. Arrangement and general neatness is satisfactory.
2. The storage area is clean (free of visible dust, spilled liquids, etc.).
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.
REVIEW SUBJECT
COMMENTS/ACTION TAKEN
(for additional comments, use last page)
CHECKED
& OK
PROBLEM
NOTED
24. Look alike/sound alike medications are labeled and/or stored in accordance with medical center policy.
30. The refrigerator is clean (free of visible dust, spilled liquids, etc.).
29. The refrigerator contains only medications and admixtures requiring storage at reduced temperatures (i.e. no food, lab specimens, etc. are present).
28. No prescription pads are in unsecured, open areas.
27. Controlled medications (CII through CV) are secured in accordance with medical center policy.
26. Medications are available in the most ready to administer forms available from the manufacturer.
25. High Alert medications are labeled and/or stored in accordance with medical center policy.
C. Refrigerator
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 Nursing Reviewer Original Copy retained in Pharmacy. Copies of completed form to Nursing Service and Chief of Staff Pharmacy Reviewer
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