Potassium chloride 20 mmol/10 mL — lot LOT-I7925
14 of 14 points observed
Medication tracer — cold-chain and high-alert supply · Ravi Shanmugam
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
Potassium chloride 20 mmol/10 mL — lot LOT-I7925
Medication tracer — cold-chain and high-alert supply · Pharmacy
- Point Compliance
- 67%
- 12 checkpoints scored
- Findings Raised
- 2
- Actionable deficit citations
- Surveyor Sign-off
- Ravi Shanmugam
- Attested 2026-09-16
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- FMS2 checkpoints2 gaps0%
- QPS2 checkpointsClean50%
- COP1 checkpointClean50%
- MMU12 checkpoints2 gaps67%
- IPSG2 checkpointsClean100%
- PCI1 checkpointClean100%
- MOI1 checkpointClean100%
Findings Raised During Trace (2)
- Dr. Fatima Al-Mansoor · Due 21 Sep 2026criticalIndependent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%.
- Dr. Priya Sharma · Due 27 Oct 2026highEvidence gap identified for MMU.4 during mock surveyor; requires documented remediation. (demonstration)
What you have recorded
14 of 14 points- ReceiptPartial
Goods-in verification
Two of the sample met the standard in full; the remainder were missing a timed signature.
Pharmacy·9 of 10 records compliant·demonstrated·MMU·3 evidence artifacts - ReceiptPartial
Rejection handling
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
Pharmacy·6 of 10 records compliant·described·MMUQPS·1 evidence artifact - StorageNon-compliant
Cold-chain monitoring
Staff described the correct process but could not demonstrate it, and no record exists for the period.
Pharmacy·8 of 10 records compliant·described·MMUFMS·3 evidence artifacts - StorageNot applicable
Expiry and stock rotation
No patients meeting the criterion were present during the trace.
Pharmacy·MMU·3 evidence artifacts - DispensingCompliant
Prescription review
Staff demonstrated the step without prompting and produced the record on request.
Pharmacy·9 of 10 records compliant·demonstrated·MMU·1 evidence artifact - DispensingCompliant
Look-alike sound-alike segregation
Practice at the bedside matched the written process; the record was complete and timed.
Pharmacy·5 of 10 records compliant·demonstrated·MMUIPSG·1 evidence artifact - PreparationCompliant
Aseptic preparation
Asked two members of staff independently; both described the same process and located the evidence.
Pharmacy·9 of 10 records compliant·described·MMUPCI·2 evidence artifacts - PreparationCompliant
Preparation labelling
Staff demonstrated the step without prompting and produced the record on request.
Pharmacy·7 of 10 records compliant·described·MMU·2 evidence artifacts - AdministrationCompliant
Independent double-check
Practice at the bedside matched the written process; the record was complete and timed.
ICU·5 of 10 records compliant·demonstrated·MMUIPSG·1 evidence artifact - AdministrationCompliant
Administration recording
Asked two members of staff independently; both described the same process and located the evidence.
ICU·6 of 10 records compliant·demonstrated·MMUMOI·1 evidence artifact - MonitoringPartial
Monitoring of medication effect
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
Pharmacy·5 of 10 records compliant·demonstrated·MMUCOP·1 evidence artifact - MonitoringPartial
Adverse event and near-miss reporting
Practice was correct where observed, though staff could not locate the governing document on the unit.
Pharmacy·8 of 10 records compliant·described·MMUQPS·1 evidence artifact - Waste and returnNon-compliant
Controlled drug waste
The evidence produced contradicts the written process for this unit.
Facilities·4 of 10 records compliant·demonstrated·MMUFMS·1 evidence artifact - Waste and returnNot applicable
Hazardous waste segregation
No patients meeting the criterion were present during the trace.
Facilities·FMSPCI·2 evidence artifacts