medication cart / treatment cart - medical pharmacies · pdf filequality assurance audit of...

© 2011 Medical Pharmacies Group Inc.

Quality Assurance Audit of Medication Systems

Medication Cart / Treatment Cart of 3 (Cart)

Objective: To demonstrate that storage of medications meets legal and facility standards. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________

Clinical Consultant Pharmacist Quality Assurance Technician COPIES TO: __________________

INDICATOR Met Not Met

LTCHA MP P&P COMMENTS

MEDICATION/TREATMENT CART

1. The medication/treatment cart is locked or kept in a locked room.

2. Cart is clean and well organized. • surface wiped clean after each medication

pass • bins cleaned regularly and when resident

is discharged • cart is cleaned following any outbreak

3. Discontinued or expired medications have been removed (regular/narcotic/PRNs/ treatments and stock).

4. No unlabelled medication samples. 5. All medications are kept in the original

labeled container. 6. All drugs with illegible labels are removed for

disposal 7. No family supplied medications 8. No handwritten changes to directions on

label or card (except by physician or pharmacist).

9. External and internal medications are stored

separately. 10. Medications are dated when opened and

replaced when expired: • Eyedrops………………….3 months or as labeled • Miacalcin……………...….4 weeks • Nitrostat……………….….12 months • Inhalation solutions ……..28 days

ipratropium, salbutamol) • Sterile water / Sodium Chloride for irrigation… 7 days • Gravol multidose • Morphine multidose • B12 • Modecate • Xylocaine • Methotrexate

11. Eye drops are labeled with individual

resident’s name, (eg. Isopto Tears)

129.1.a.ii

114.2 3-5

114.2 136.2.i

5-5

122.1.b MSSA 68

126

136.1.b

122.1.b

114.2 4-9

114.2 3-3

114.2 129.1.a.iv

5-2

To be completed every 6 months








12. Creams, ointments, etc. supplied in a bulk container are not used for more than one resident. (Infection control practices)

13. Unused portions of medicated and sterile

dressings are discarded as per manufacturer direction.

14. Inhalers are capped and aerochambers are

stored hygienically and cleaned weekly. (Infection control practices)

15. Back-up keys can be accessed if needed.

• stored in ______________________ 16. Separate reorder labels are stored in a

systematic manner & current. NARCOTIC AND CONTROLLED MEDICATIONS

17. All Narcotic and Controlled substances are kept under double lock until destruction.

18. Only Narcotic and Controlled substances are

stored in Narcotic & Controlled med bin. 19. N & C Count Records are accurate.

• wasted narcotics are double signed 20. Narcotic / Controlled Shift Count completed

by 2 nurses each shift change. • discontinued medication will continue to

be counted until removed

21. Monthly audit of shift count sheets is completed to identify discrepancies.

MULTIDOSE CARDS OR STRIPS

22. Resident sections are clearly labeled (bins or divider cards).

23. Discontinued drugs are correctly identified on

all packets in current multidose strip. 24. Vials are current and orders not duplicated in

the strip/multi-dose card.

129.1.a.iv

114.2 3-4

114.2 4-11

129.1.b

129.1.b

129.1.b 6-6

114.2 6-7

130.3

114.2 12-4 3-4

114.2 12-11

114.2 12-9









25. Time changes are addressed safely on all

multi-dose packaging. 26. Standard HOA’s are used except when

specifically requested otherwise.

114.2 12-10

114.2 12-6

Other:




Medication StoragePage 1 of 2 (Storage)

Objective: To demonstrate that storage of medications meets legal & facility standards.

FACILITY: ____________________________________ UNIT: _________ DATE: _________________

AUDITED BY: ______________________________ DISCUSSED WITH: _________________________



LTCHA MP P&P COMMENTS FOLLOW

UP / WHOMEDICATION ROOM / NURSE’S STATION

1. Locked or cupboards locked. 2. No hazardous chemicals or cleaning

compounds stored in medication rooms. 3. Lighting is adequate to clearly read labels. 4. Medical Pharmacy’s phone, fax, pager &

Consultant Pharmacist number posted & current.

5. Poison control centre contact information is

available (see pharmacy contact numbers form).

6. References available

• Medical Pharmacy P & P Manual • CPS or e-CPS • ODB formulary or e-Formulary

STOCK MEDICATIONS

7. No more than a 3-month supply of drugs for a resident

8. Internal medications are separated from

external. 9. No expired medications. 10. No items requiring refrigeration stored at room

temperature. REFRIGERATOR

11. Refrigerator is in locked room or medication box is locked.

12. Vaccines are stored away from the door.

• temperature of vaccine fridge is monitored and recorded daily (Public Health recommendations)

13. All discontinued and expired medications and

vaccines have been removed. 14. Insulin vials, vaccines and Tuberculin PPD are

dated when opened & discarded after 30 days or as recommended by manufacturer.

130.1

MSSA 74

MSSA 80

118.2

118.3

118.1 MSSA 17

124

114.2 3-3

136.2.1

129.1.a.iv

130.1

136.2.1

129.1.a.iv




Medication StoragePage 2 of 2 (Storage)

Objective: To demonstrate that storage of medications meets legal & facility standards.

FACILITY: ____________________________________ UNIT: _________ DATE: _________________

AUDITED BY: ______________________________ DISCUSSED WITH: _________________________




UP / WHO

15. Thermometer available in any fridge used for medication storage. • refrigerator temperature is between 2º-

8ºC (36º F - 46ºF)

16. Refrigerator is used solely for the storage of medications and vaccines.

EMERGENCY STARTER BOX

17. Procedures for use are followed correctly. • re-ordered from pharmacy in ESB

DRB • signed in on the ESB DRB

18. Only and all medications are present as per facility’s Master List. • list updated annually, last review

__________________ • stock monitored regularly on ESB

monitoring form 19. No outdated medications.

20. Box is stored in a locked room or cupboard 21. Narcotic and Controlled Substances are

• stored under double lock • counted at shift change by 2 nurses

22. Appropriate clinical information is available

(e.g. warfarin DI, morphine dose calc chart, etc.)

129.1.a.iii129.1.a.iv

129.1.a.i MSSA 85

123.b 114.2 2-4

123.c

136.2.1

130.1

129.1.b 114.2 6-7

MSSA 17MSSA 19




Insulin Delivery and MonitoringPage 1 of 2 (Ins)

Objective: To demonstrate that storage of Insulin, Glucose Monitoring Device and Lancing devices meet standards for safe use. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________


INDICATOR Met Not Met LTCHA MP P&P COMMENTS FOLLOW

UP / WHOINSULIN 1. Pen (barrel) is labeled with resident’s

name. 2. Current cartridge/vial on cart has been

dated when opened. • all insulin dated less than 1 month

3. Needle tips

• have been removed from pen • safety needle tips in use (Occupational Health & Safety Act, Needle Safety Regulation (O. Reg. 474/07) )

4. Product for hypoglycemic rescue on hand.

• Glucagon • 15g carbohydrate (CDA clinical practice guidelines of Hypoglycemia 2008)

5. MAR documentation indicates injection

site and time. 6. Insulin cartridge in pen matches insulin

type on MAR. (CNO practice standard medications revised 2008)

7. Current insulin vials and pen are stored at

room temp. 8. The types of insulin pens are limited.

• Instruction available for pens in use BLOOD GLUCOSE METERS 9. Only one box of strips open per meter. If

multiple boxes, ordered and used in organized manner. • strip canisters are dated when opened

129.1.a.iv5-1

129.1.a.iv

MSSA 78

114.2 5-2

To be completed annually



Insulin Delivery and MonitoringPage 2 of 2 (Ins)

Objective: To demonstrate that storage of Insulin, Glucose Monitoring Device and Lancing devices meet standards for safe use. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________




UP / WHO 10. Meter is cleaned with an appropriate

cleaning compound e.g. accelerated hydrogen peroxide (In accordance with Public Health policy)

11. Meter accuracy checked with control

solution or with lab comparison within past month/week according to manufacturer recommendation.

(In accordance with Manufacturers Recommendations)

12. Control solution dated when opened and discarded after 6 months. (In accordance with Manufacturers Recommendations)

13. Blood glucose readings are systematically

recorded. (CNO Nursing practice standards documentation revised 2008)

14. Meters for individual resident use are

labeled with resident’s name. (CDC handout recommended infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens)

LANCING DEVICES 15. Lancing device assures no cross

contamination among residents: • individual device used per resident • disposable lancets used • “institutional use” approved device

used (CDC handout recommended infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens; Health Canada Advisory March 24, 2009)




Documentation and AdministrationPage 1 of 2 (Doc)

Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________




UP / WHOMAR SHEETS

1. Master Signature list is current. (CNO Communication p 6 h)

2. All medications are signed for on MAR and

codes used appropriately. 3. New orders include drug name, strength,

directions for use, HOA, route and date of order. MAR signature boxes are blocked off appropriately.

4. Change of orders is correctly documented.

• old order discontinued • new order written

5. Discontinued orders are clearly documented. 6. If a range dose, quantity given is documented.

(CNO) 7. MARS signed and dated as being checked as

per facility policy. 8. MARS are blocked off correctly for q2d, MWF,

etc. orders. 9. Drug Interaction Alert notice communicated

with MD and placed with MAR. 10. MAR book is kept in a secure, private location

when not in use, or eMAR screen closed. (CNO Security P.8 b)

11. e-MAR orders indicate correct source of

medication. (MP Med-e-Link procedure guide for PCC) 12. Self administered medications have an order

to allow self administration • medications are stored securely

PRN DOCUMENTATION

13. PRN orders include: • frequency • indications for use

114.2 8-1

114.2 131.2 8-1

114.2 8-3

114.2 8-3

114.2 8-3

114.2 8-2

114.2 8-3

114.2 9-3

114.2

131.6 114.2 5-5

114.2 8-4




Documentation and AdministrationPage 2 of 2 (Doc)

Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________




UP / WHO

14. Documentation of administration is noted on MAR’s +/or, back of MAR, PRN sheet or progress notes. • flagging system in place to remind

nurse to follow-up 15. Documentation includes:

• reason for use • effect of dose given

TREATMENT SHEETS

16. Order includes: • frequency • area to be treated

17. All treatments are signed for or codes used

appropriately. 18. New orders include drug name, strength,

directions for use, HOA, and date of order. TAR signature boxes are blocked off appropriately.

19. Change of orders is correctly documented.

• old order discontinued • new order written

20. Discontinued orders are clearly

documented. 21. Observations are noted at least every 7

days by a nurse. 22. TARS are signed and dated as being

checked as per facility policy. 23. Self administered treatments have an order

to allow self administration

• treatments are stored securely

114.2 8-4

114.2 8-4

114.2 8-1-1

114.2 8-1-1

114.2 8-1-1

114.2 8-1-1

114.2 8-1-1

114.2 8-1-1

114.2 8-2

131.6 114.2 5-5

Other: To be completed every 6 months



Drug Record BookPage 1 of 1 (DRB)

Objective: To demonstrate that proper procedures for documenting of ordering and receiving of medications meets legal and facility standards.

FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________




UP / WHODRUG RECORD BOOK (Non Multi-Dose Meds)

1. All medications ordered are identified by signature/initials and dated. • new orders • refill orders

2. All medications received are identified by signature/initials and dated.

3. Drug Record Book page indicates which orders have been faxed to pharmacy.

4. Drug Record Book pages are used in sequence and unused boxes are crossed off.

5. All Drug Record Book sheets are kept for 2 years.

6. Quantity and Rx # received is recorded for all new orders (circled on reorders).

7. Medication Starter Packs are reordered correctly with original order and starter pack re-order label. (may be in separate ESB DRB)

8. BPMH Reconciliation / Admission orders Drug Record Book Page indicates: • drugs ordered • drugs not to be sent • drugs received with date, qty & Rx #

9. Bulk ordering system follows policy eg. lactulose, soflax, BG strips.

10. Pharmacy Nursing Communication sheets are filed in the DRB and addressed in a timely manner.

11. All other pharmacy forms are filed appropriately (ie. Drug Interaction Alert in Narcotic and Controlled med count binder on cart).

DOCUMENTATION OF RECEIVING MULTI-DOSE CARDS OR STRIPS

12. Shipping Report is checked against each resident’s name, signed and dated.

13. Shipping Reports are filed in chronological order and kept for 2 year

133 4-1

133 4-1

133 4-1

133 4-1

133 4-1

133 4-1

133 4-1

133 4-3

114.2 10-7

114.2 4-10

114.2 9-3

4-13 4-14

133 114.2 12-9

133

114.2 12-9




Resident Safety AuditPage 1 of 4 (RSA)

Objective: To demonstrate that proper procedures for documentation, transportation and availability of medications meet legal and facility standards.

FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: _________________________________ DISCUSSED WITH: _________________________


Resident Charts Reviewed

INDICATOR LTCHA MP P&P Met Not

Met Met Not Met Met Not

Met Met Not Met

PHYSICIAN’S ORDERS

1. All orders: • are legible and clear • no missing info, eg. doses, frequency,

strength, route, indication (CNO Assessment P.4)

2. No inappropriate abbreviations used

• OD, QD, OU, OS • cc • U or u, IU • ss or SS • HS • other _____

3. No trailing zeros after decimal points or

naked decimal points.

eg. 1.0 mg use 1 mg .5 mg use 0.5 mg

4. All information complete at top of each

physician order sheet: • resident first & last name • facility name • allergies , room / unit

5. All orders are signed or cosigned by

physician: • written orders are signed and dated • telephone orders are signed and dated

by the nurse and cosigned by the physician within 7 days.

6. A medical directive is in place to authorize

Physician Assistant to sign orders. • Physician and Physician Assistant’s

names clearly stated on Medical Directive

• A copy of the Medical Directive is located:

in the dispensary in ____________ in the home in ________________

• accessible to staff at any time

114.2 2D

MSSA 31MSSA 32

114.2 3-9

MSSA 33

114.2 3-9

MSSA 33

114.2 4-2

114.2 4-2

MSSA 38





Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: _________________________________ DISCUSSED WITH: _________________________

Clinical Consultant Pharmacist Quality Assurance Technician COPIES TO: __________________ Resident Charts Reviewed



Met Met Not Met

7. Orders are faxed or sent via digital pen. 8. Admission or re-admission orders include

the prescribing physician’s name. 9. Order sheets of residents with same or

similar names are differentiated. MEDICATION REVIEW FORMS 10. Nurse prechecks and dates as per facility

policy. 11. Unused lines have been crossed off after

physician has signed. 12. Copy has been sent to pharmacy. 13. After Medication Review signed, a new

Physician’s Order Sheet is started and previous blank spaces crossed off.

14. Physician’s orders and Medication Reviews

in chart are together in chronological order. 15. Medication Review has been completed

within the past quarter (or as per policy for Retirement Home residents).

16. CrCl has been calculated within past 12

months and printed on medication review. MAR/TARS

17. All orders are: • accurately transcribed from Physician’s

orders • no inappropriate abbreviations • orders are transcribed to MAR or TAR

according to facility policy. 18. Crushing:

• only suitable medications are identified to be crushed

• residents requiring crushed medications are identified

19. Allergies noted

114.2 4-2

114.2 4-3

MSSA 11

114.2 8-5

114.2 8-5

114.2 8-5

114.2 8-5

114.2 8-5

134.c 114.2 8-5

MSSA 15

114.2 8-3

114.2 3-9

114.2 8-1-1

114.2 5-3

114.2 8-2






Clinical Consultant Pharmacist Quality Assurance Technician COPIES TO: __________________ Resident Charts Reviewed



Met Met Not Met

MEDICATIONS 20. All ordered medications are available in

appropriate quantities. 21. No discontinued or expired medications on

hand. 22. All medications properly labeled and

stored. 23. Cytotoxic medications are

• packaged separately and appropriately labeled

• injectable and topical cytotoxics are stored in a resealable plastic bag

MEDICATION RECONCILIATION 24. Best Possible Medication History (BPMH)

information includes: • allergies • drug, dose, frequency, route • info from two sources

all orders from all sources included in BPMH

• new, continue box checked and discontinue box X’d out

code indicated for discontinued order and order clearly crossed out

• ‘list recorded by’, ‘telephone order taken’ by completed

MEDICAL DIRECTIVES 25. Medical directives are written out in full on

the MAR when used • order is clearly identified as a medical

directive 26. Medical directive exceptions and allergies

are clearly noted on order sheet, MARS, TARS and QMR.

27. Each medical directive individually

authorized by the physician on order sheet.

28. Medical directives used only for appropriate indication.

124

114.2 136.1.a 136.1.d.i

5-4

129.1.a.iiiMSSA 48

114.2 5-6

114.2 10-8

114.2 8-3

117

117

117







RESIDENT COMMENTS FOLLOW UP / WHO




Medication Pass Page 1 of 2 (MP)

Objective: To ensure that safe procedures and correct techniques are followed. To promote efficiency on giving out medications. To assist the professional team in optimizing treatment outcomes.

FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ________________________ DISCUSSED WITH: _________________________ Clinical Consultant Pharmacist COPIES TO: _______________________________ PASS TIME: _________________ NURSE/UCP DOING PASS: _____________________ DATE: __________



UP / WHOMEDICATION PASS

1. Drug cart is kept in line of sight or locked at all times.

2. eMAR screen is locked when nurse is away from cart OR patient information protected when MAR book not attended by nurse (CNO P.8 B)

3. No drugs outside the cart during med pass.

4. A flagging system is used to ensure no residents are missed.

5. Minimal interruption during the med pass.

6. All medications and supplies are available on cart.

7. Lighting is adequate to clearly read MARS and labels.

ORAL MEDICATIONS

8. Nurse checks each medication systematically against the MAR sheet.

9. MAR Sheet is signed at the time the medication is given (no prepour).

10. Pills are not touched by hand.

11. Oral liquids poured at eye level.

12. Suspensions are shaken before pouring.

13. Medications only crushed when noted on MAR sheet.

14. Resident positioned properly, ie. not lying down or about to.

15. Medications are not left at table or in resident’s room unless there is a physician’s order.

16. All medications are given correctly in relation to meals (ac/with food).

129.1.a.ii

129.1.a.ii 114.2 3-6 12-5

114.2 3-6

MSSA 80

114.2 3-6

114.2 3-6

114.2 5-3

5-5

131.2

To be completed at the request of the facility or at the discretion of the Clinical Consultant Pharmacist



Medication Pass Page 2 of 2 (MP)

Objective: To ensure that safe procedures and correct techniques are followed. To promote efficient use of nursing time spent on giving out medications. To assist the professional team in optimizing treatment outcomes. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ________________________ DISCUSSED WITH: ________________________ Clinical Consultant Pharmacist COPIES TO: ______________________________ PASS TIME: _________________ NURSE/UCP DOING PASS: _____________________ DATE: __________



UP / WHO NON-ORAL MEDICATIONS 17. Proper procedures are used for the

administration of:

• ophthalmics • otics • inhalers & aerochambers • nasal preparations • patches • insulin

18. Resident dignity is respected. 19. Proper sanitation used and hand

hygiene. INSULINS 20. Swab top of insulin cartridge or vial

before applying needle. 21. Air is expelled before each injection with

the 2 unit test. 22. Suspensions are rolled correctly. 23. Insulin is given at correct time in relation

to when resident eats. 24. Needles and lancets are disposed of

safely:

• no recapping of needles • safety needles in use • discarded in sharps container

To be completed at the request of the facility or at the discretion of the Clinical Consultant Pharmacist



Medications for DisposalPage 1 of 2 (MD)

Objective: To ensure that all medications are administered as ordered. To ensure accountability for all medications through the disposal process. To identify discrepancies with charting of medications. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: __________________________________ DISCUSSED WITH: _______________________




UP / WHODISCONTINUED MEDICATIONS 1. Are removed from cart same day 2. All Narcotics & Controlled medications

• are maintained under double lock until disposal (may use a N&C mailbox)

• the “Drug Destruction and Disposal” record is complete, double initialed and kept with meds until disposal (use binder)

• continue to count until they are removed from the cart into a N&C mailbox or separate double locked secure one way storage

3. Used medication patches are discarded appropriately. • in medication disposal

STRIP PACKS 4. All strip packs for disposal have either

• a code for withholding medication code same as MAR code

• a direction change sticker and/or affected order circled

MAR reflects direction change tablet identified on pouch matches discontinued order

5. Pharmacy has been notified of discharge

of residents (identified by presence of full strip packs)

6. Codes for withholding medications used

appropriately

• code 7 (sleeping) not used for essential medications

• code 3 (away from home without medications) is not used if LOA medications could have been sent with the resident.

136 114.2 5-4

129.b 114.2 6-5

114.2 6-5

114.2 12-5

114.2 12-10

121 114.2 7-5




Medications for DisposalPage 2 of 2 (MD)

Objective: To ensure that all medications are administered as ordered. To ensure accountability for all medications through the disposal process. To identify discrepancies with charting of medications. FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: __________________________________ DISCUSSED WITH: _______________________




UP / WHOVIALS 8. No medications remaining in vials

containing short term medications.

• if tablets remain, MAR indicates medication has been appropriately held or discontinued

• Emergency Starter Box meds, if used, were ordered and pharmacy notified.

131.2

114.2 2-4


DISCREPANCIES (attach packets if applicable)



Med-e-Pen AuditPage 1 of 2 (Med-e-Pen)

Objective: To demonstrate that Med-e-Pen is functioning effectively and is used properly to transmit physician orders to pharmacy FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________


INDICATOR Met Not Met COMMENTS FOLLOW

UP / WHO Med-e-Pen Hardware:

1. Med-e-Pen is fully charged or charging.

2. Med-e-Pen is positioned correctly in cradle at all times while not in active use.

3. Med-e-Pen cradle is attached to computer and is physically accessible to registered staff and physicians.

4. Med-e-Pen cap is present/available. Med-e-Pen Software and Connectivity: 5. When Med-e-Pen is docked during audit,

computer screen shows “nothing to download”.

6. Internet access is active on computer. 7. Registered staff is able to log into computer

(windows application). 8. Med-e-Pen software icons are visible on

computer screen. 9. Writing and sending a test order via Med-e-

Pen is successful. 10. Viewer is accessible (using unit

login/password). (Record IP address and provide to Medical Pharmacies if not).

11. Registered staff is aware of how to access

viewer and routinely does so each time orders are sent via Med-e-Pen (or at end of shift at minimum).

12. Physician orders in viewer display same

information as is visible on physician order sheets in charts.




Med-e-Pen AuditPage 2 of 2 (Med-e-Pen)

Objective: To demonstrate that Med-e-Pen is functioning effectively and is used properly to transmit physician orders to pharmacy FACILITY: ____________________________________ UNIT: _________ DATE: _________________ AUDITED BY: ______________________________ DISCUSSED WITH: _________________________


INDICATOR Met Not Met COMMENTS FOLLOW

UP / WHO

Charts: 13. All physicians order sheets in chart contain

complete header information written with digital pen.

14. Digital pen is always used on digital paper (no evidence of different pen ink etc.).

Registered Staff knowledge of Med-e-Pen: 15. Registered staff on duty is aware of location

of: • Ink refills • Spare digital pen for emergencies • Physicians order sheets • Med-e-Pen instructions

16. Registered staff demonstrates knowledge of how to confirm that an order has been sent via Med-e-Pen (via confirmation message and viewer access).

17. Registered staff knows procedure of sending

orders to pharmacy in case of pen transmission failure (photocopy digital paper or print from viewer, fax to pharmacy).

Other: To be completed every 6 months


Facility: _______________________________________

Type of Audit Completed Date Audited Unit

Cart Storage Ins Doc DRB RSA ICA MP MD Med-ePen

Notes

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