Pharmacy Auditor Checklist
For High Alert Medications
Audit
Covenant Health Medication Management Safety Team
March 2015
Pharmacy‐ Audit Checklist for High Alert Medications (HAMs).
Pharmacy Managers are responsible to ensure audits are completed in all
areas of Pharmacy. Auditors will be given from May 4, 2015 to June 30, 2015
to complete audits for all high alert medications in their designated areas.
Audit Tools and an Audit Tool Kit will be sent to Pharmacy Managers May 4,
2015.
Audit Tools, an Audit Tool Kit and HAM educational resources are also
available on CompassionNET
: http://www.compassionnet.ca/Page465.aspx
General Audit HAMs Pharmacy
Audit 1 ‐The General HAMs Pharmacy Audit evaluates HAMs on the Covenant
Health HAMs List that are available in all areas of Pharmacy only. Night
Cupboards, Code Tray filled by Pharmacy, should be included in the Audit.
*Note ‐ Program Managers/Unit Managers in patient care areas will be
responsible for auditing Automated Dispensing Cabinets(Pyxis), ward stock
carts/storage, fridges and code trays (non pharmacy) filled & maintained by
units.
The Audit Tool Kit and educational resources provide the auditor with the
information required to complete the HAMs audit. Review the HAMs Audit
tool kit and have the kit available for reference while completing the audit.
Resources‐ Quick Links
For a list of Alphabetized list of High Alert Medications refer to:
Covenant Health High Alert Medication Alphabetized List or
High Alert Medication Poster
Approved ROPE and associated safeguards are available on Compassion Net:
http://www.compassionnet.ca/Page465.aspx
For Storage & Labeling Guidelines refer to:
High Alert Medication Labeling and Storage Guidelines for Pharmacy
XI-20 Labeling Policy and Procedure December 2014
For a Tallman lettering list refer to:
Pharmacy Services Tall Man Lettering List
For applicable auxiliary labels refer to page 15:
High Alert Medication Labeling and Storage Guidelines for Pharmacy
For Prohibited Abbreviations Poster
Prohibited Abbreviation Poster
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Pharmacy Managers ‐ Audit Checklist for High Alert
Medications (HAMs).
Key storage guidelines for HAMs
Look‐alike medications shall be physically separated in
separate non‐adjacent bins, unless this separation is likely to
introduce a new risk for selection error as a result (one strategy
is to put an empty box or bin to make a separation between
bins).
When physical separation is not possible, use sound‐alike/look‐
alike auxiliary labels to alert staff of potential selection error.
Insulin’s are to be organized by duration of action (i.e., rapid,
short, intermediate and long acting).
Oral narcotics with long acting dosage formats are to be
segregated from those that are in short acting dosage formats.
Injectable and Oral medications to be segregated.
Heparin vials/ampoules are to be stored separately from
heparin lock solutions/syringes.
Program/Unit Managers, Pharmacy Services and Stores need to
collaborate to ensure proper labeling and segregated storage of
HAMs provided by Stores and Pharmacy that are available in
patient care areas. Examples of Stores HAMs:
Sterile water for inhalation, Sterile water for injection and
Radio Contrast Dye IV in Diagnostic imaging.
The auditor can fax completed audits with a cover sheet or
scan the completed audit tool to the Medication Management
Safety Team. Please retain copies of your audit sheet for
your records.
Questions: Please contact the Medication Management
Safety Team. 780-342-9013
FAX: 780-342-9045(with cover sheet)
or
E-mail: Medication.Management@covenanthealth.ca
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