Compounding Sterile Products (USP 797)
This is the appropriate SOP for donning PPE prior to entering the SCA.
What is Don shoes, head PPE, facial mask, wash hands, gown, sterile gloves
Who is the Corporate Compliance Officer (hint for the entire Enterprise)?
Who is Lori Strauss
Not everyone can shut off the oxygen. Who are the designated people?
Director of Facilities and Engineering, in coordination with Respiratory Therapy.
What is the acronym used to identify High Alert drugs? What does each represent?
What is HIPPOS
H- Heparin and anticoagulants
I Insulin
P Potassium and Pitocin
O opioids
S (Hypertonic) Saline
Hospital wide changes regarding pharmaceuticals go to which committee first.
What is P&T
The BUD for products prepared in the CAI is
What is 48hr. RT
Where are Hazardous Chemo drugs prepared?
What is at the PFCC
The acronym R.A.C.E stands for?
What is R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
Name a process change that took place due to a medication error?
process for Cross refence of bar codes, update IV pump alert,
updated medi-dose to require pre/post check and scanning
Scanning for Pyxis refills
(any appropriate response is acceptable )
This program is designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal drug regimen, dose, duration of therapy and route of administration.
What is the Antimicrobial Stewardship Program (ASP)
The BUD of a single dose vial.
What is a) in ISO 5 environment= 6 hrs
b) outside ISO 5 = 1 hr.
Describe the process for monitoring the eyewash stations.
Bump test performed weekly.
Record temp of water by pouring water in a beaker and using the infrared thermometer (weekly).
Both are recorded on log.
The acronym "PASS" stands for?
What is PASS - P- Pull the pin A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
These are the strategies we have implemented to manage therapeutic duplication.
What is review daily "prn report" Worked with anesthesia to clarify antiemetic orders. Used linked order sets to identify multimodal therapy.
Modified clinical checking module to create a force function.
The IV to PO Switch is an example of
What is de-escalation
This is the most important step in infection prevention and for how long must this be done?
What is handwashing 30 seconds
The process for maintaining an accurate patient profile during pharmacy downtime.
What is printing downtime MARs, recording new orders on profile, For new patient call for allergies….
( Any appropriate response can be accepted)
The 2 patient identifiers are?
What are Name and DOB
These strategies are used to identify LASA drugs
What are Tallman lettering and signage, separation of bins
These two main disciplines make up the Medication Management Committee
What are Nursing & Pharmacy
Deconspor dwell time
What is 10 min.
A system of shared accountability in which the organization is accountable for the systems they design and for responding to the behaviors of their employees in a fair and just manner.
What is a just culture
This system is used to report all adverse drug events.
What is SB Safe
NPSG .03.05.01 deals with anticoagulation. Why is this important and what are some of the strategies we use?
These medications are high alert medications that can cause patient harm.
We use heparin protocols, monitor daily INR (warfarin). Created order sets. Monitor labs.
Reversal guidelines and the IPRO tool for perioperative procedures is on the intranet for reference
This updated method of Vancomycin monitoring was recently approved at ASP and calculated by Pharmacy.
What is the AUC/MIC ratio