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医疗机构合规 12 项

High-Alert Medication Independent Double-Check Audit

此检查清单为英文版。

Audit of independent double-check practices and additional safeguards for high-alert medications such as insulin, anticoagulants, opioids, and concentrated electrolytes.

ISMP High-Alert Medications ListTJC NPSG.03.05.01TJC MM.01.01.03

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High-Alert Identification

  • Does the facility maintain a high-alert medication list based on the ISMP list and internal error data? *
  • Are high-alert medications clearly identified in storage areas and in the electronic record? *
  • Are concentrated electrolytes (e.g., KCl, hypertonic saline) removed from patient-care unit floor stock? *

Independent Double-Check

  • Is an independent double-check performed by two clinicians before administering designated high-alert medications? *
  • Does the double-check independently verify drug, dose, concentration, rate, route, and patient? *
  • Is the second-verifier check documented in the medication record? *

Standardization & Technology

  • Are standardized concentrations and dosing limits used for high-alert IV infusions? *
  • Are smart infusion pumps with drug libraries and hard dose limits used for high-alert infusions? *
  • Are anticoagulant management protocols and monitoring in place per NPSG.03.05.01? *

Monitoring & Review

  • Are high-alert medication errors and near misses reported and analyzed for system causes? *
  • Is the high-alert list reviewed at least annually using internal error data? *
  • Are double-check compliance and effectiveness audited periodically?

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