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Two sample questions to prepare for survey

Pharmacy Regulation Resource, September 28, 2005

Editor's note: The following are hypothetical questions a JCAHO surveyor may ask during a survey, excerpted from the HCPro book Ready, Set, Patient Safety! Questions, Games, and Other Strategies to Prepare Your Staff, by Sandra L. Patterson, RN, BSN, MS. ©2005, HCPro, Inc. For more information, visit http://www.hcmarketplace.com.

Q: What improvement activities have you conducted regarding high-risk or high-alert medications?

Example: We reviewed data from outside sources and from our own organization to formulate our list of high-risk and high-alert medications. Once we identified those medications, we came up with processes for how they are ordered and transcribed, how we get them, where they are stored, and how they are administered and monitored.

For example, we expanded our double-check system requiring a nurse to have another nurse check the medication before the nurse administers it. We added medications to the list and stated specific information that must be verified. That list is available on all of the patient care units where those medications are given.

Q: Who is responsible for the inspection of medication storage? How is this process checked for effectiveness?

Example: The pharmacy manager is ultimately responsible for all of the medication storage at the facility. However, individuals from the pharmacy and those within departments where medications are stored have certain defined daily responsibilities to make sure that the medications are properly stocked, rotated, and checked for expiration dates and appropriate warnings.

Any time we have an occurrence or a near-miss associated with the way a medication was stored, we report that on our occurrence form and a follow-up is done.
 

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