TR-10activePharmacy

Vancomycin 1 g powder — lot LOT-L5217

8 of 14 points observed

Medication tracer — cold-chain and high-alert supply · Dr. Miriam Haddad

Point 9 of 14Administration, Ward 4A Medication RoomCritical standardNot observed

Independent double-check

MMUIPSGMMU.6IPSG.3

What to observe

Find the independent double-check for this high-alert dose. Check two qualified staff verified separately — not together — covering patient, drug, dose, route and rate, both recorded at administration. Record any single signature.

What good looks like

Two qualified staff checking independently rather than together, verifying patient, drug, dose, route and rate, both recorded at the time of administration.

What did you find

Attach what you were shown

Captures are synthetic demonstration records drawn from a seeded hospital library. Extracted values are editable for survey training and are not read from an external image.

What you have recorded

8 of 14 points

Receipt
Goods-in verification
Compliant
Staff demonstrated the step without prompting and produced the record on request.
Pharmacy·4 of 10 records compliant·described·
MMU
·3 evidence artifacts
Receipt
Rejection handling
Compliant
Practice at the bedside matched the written process; the record was complete and timed.
Pharmacy·6 of 10 records compliant·demonstrated·
MMUQPS
·1 evidence artifact
orientation_record_v1.xlsx
Storage
Cold-chain monitoring
Compliant
Asked two members of staff independently; both described the same process and located the evidence.
Pharmacy·4 of 10 records compliant·described·
MMUFMS
·3 evidence artifacts
medication_double_check_policy_v3.pdf
Storage
Expiry and stock rotation
Partial
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
Pharmacy·10 of 10 records compliant·described·
MMU
·3 evidence artifacts
Dispensing
Prescription review
Partial
Practice was correct where observed, though staff could not locate the governing document on the unit.
Pharmacy·8 of 10 records compliant·described·
MMU
·1 evidence artifact
orientation_record_v1.xlsx
Dispensing
Look-alike sound-alike segregation
Non-compliant
The evidence produced contradicts the written process for this unit.
Pharmacy·7 of 10 records compliant·described·
MMUIPSG
·1 evidence artifact
Finding #F-0238 Raised
Preparation
Aseptic preparation
Not applicable
No patients meeting the criterion were present during the trace.
Pharmacy·
MMUPCI
·2 evidence artifacts
Preparation
Preparation labelling
Compliant
Practice at the bedside matched the written process; the record was complete and timed.
Pharmacy·6 of 10 records compliant·demonstrated·
MMU
·2 evidence artifacts

Independent double-check

What you have recorded

Goods-in verification

Rejection handling

Cold-chain monitoring

Expiry and stock rotation

Prescription review

Look-alike sound-alike segregation

Aseptic preparation

Preparation labelling