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Healthcare Facility Compliance 17 items

Medication Management & Safety Audit

Audit of the medication-use process from selection and storage through administration and monitoring, aligned to Joint Commission MM standards and CMS pharmaceutical services requirements.

TJC Medication Management (MM)CMS 42 CFR 482.25CMS 42 CFR 483.45

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Storage & Security

  • Are medications stored securely, at proper temperature, and inaccessible to unauthorized persons? *
  • Are controlled substances stored securely with accurate perpetual inventory and reconciliation? *
  • Are expired, damaged, or recalled medications identified and removed from stock? *
  • Are refrigerator/freezer medication temperatures monitored and logged daily? *

High-Alert & Look-Alike/Sound-Alike Medications

  • Is there a list of high-alert medications with safeguards to reduce the risk of errors? *
  • Are concentrated electrolytes (e.g., KCl) removed from patient care areas or specially controlled? *
  • Is there a managed list of look-alike/sound-alike (LASA) medications with mitigation strategies? *

Ordering, Review & Reconciliation

  • Is each medication order reviewed by a pharmacist for appropriateness before the first dose (except emergencies)? *
  • Is medication reconciliation performed at admission, transfer, and discharge? *
  • Are verbal/telephone orders read back and authenticated within the required timeframe? *

Preparation & Administration

  • Are medications administered following the rights of medication administration and the five identifiers? *
  • Are all medications and solutions labeled on and off the sterile field? *
  • Is compounded sterile preparation performed in compliance with USP <797>? *
  • Are hazardous drugs handled in compliance with USP <800>? *

Monitoring & Adverse Drug Events

  • Are adverse drug events, medication errors, and near misses reported and analyzed? *
  • Are patients on anticoagulants monitored per an evidence-based protocol? *
  • Is drug regimen review performed (monthly in LTC) by a licensed pharmacist? *

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