Department of Pharmacy

Nursing Unit / Clinic Audit Criteria

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Audit Criterion

Standard

1

Is the drug inventory of adequate size without overstocking?

  1. Drugs are kept in proper locations
  2. Medication stock levels appropriate
  3. Medication stock appropriate for area
  4. All medications secure

2

Are the dates of reconstitution and initials on all opened multiple dose vials.

Vials should indicate date of reconstitution, expiration date, and initials.

3

Have all multiple dose vials that appear to have deteriorated been removed from the drug storage area?

  1. No discoloring or turbidity.
  2. No deterioration of vial

4

Are all medications in stock within the assigned expiration date?

  1. Room temp storage exp. date indicated on label (eg, insulin)
  2. Single dose vials, once entered, have been discarded
  3. Check stock in patient drawers, Pyxis, clinic stock areas, refrigerated stock, and medication cart

5

Does the medication refrigerator have a working thermometer?

  1. Refrigerator labeled properly
  2. Has working thermometer

6

Is the refrigerator operating within an acceptable range (36-46 degree F or 2-8 degree C)

Temperature within acceptable range (document temperature)

7

Is the medication refrigerator free of food and specimens or inappropriate objects?

No food or specimen in refrigerator (controls for lab tests are okay if not judged to be toxic if inadvertently injected)

8

Does the refrigerator have a temperature log, and are the temperatures documented each business day on this sheet?

  1. Refrigerator temperature should be documented daily by nursing staff each business day.
  2. Past temperature logs should be kept for at least 12 months

9

Does the unit contain drug dosage conversion tables and reference books?

  1. Conversion Table displayed or available
  2. Current Inpatient/Outpatient Formulary
  3. Poison Antidote Chart
  4. Current Nursing references (no older than two years)

10

Are all medications properly labeled?

  1. Patient name (when applicable)
  2. Drug name
  3. Drug strength
  4. Directions for use (when applicable)
  5. Expiration date (when applicable)
  6. Signed by an RPh (when applicable)

11

Is the medication cabinet/cart locked when not in use?

  1. Medication cart locked, and autolock feature activates within approximately 90 seconds
  2. Pyxis functioning properly.

12

Are external items stored separate from internal items?

In clinic areas, medications should be separated

13

Is the medication cart/storage are clean?

  1. Top of medication cart clean
  2. Top of Pyxis clean
  3. Pill cutter - should have no residue
  4. Mortar and pestle
  5. Medication drawers clean
  6. Medication drawer labeled properly

14

Is the poison chart a conspicuous place?

Can the nurse on the unit locate the chart?

15

Code (Crash) Cart

Check the crash cart if there is one present on the unit (for exp date and security). Most units share carts (1 per floor in JS towers)

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