DNV Survey Readiness

Policies/Guidelines/Procedures

100

Policy 6.12

Unusable Drugs

200

Policy 594.00

Handling of Hazardous Drugs 

300

Policy 1.10

Department of Pharmacy Mission and Vision

400

Policy 3.14

Compounded Sterile Preparation

500

Policy 521.00

Patient Medications Brought from Home

Environment of Care

100

All medications, syringes, and needles are to be ___

Secured. This implies that medications are either attended by a nurse, physician, or pharmacist or locked up securely.

200

Check any drawers and carts for ___ items.

Outdated/Expired

300

No items are to be stacked within ___ inches of the ceiling. 

18 inches

400

Refrigerator/Freezer calibration certificates and compounding hood certification are within ____

the date (1yr)

500

Sharps containers should be changed out when ___ full and must be secured. 

2/3

Medication Safety

100

You must always use __ patient identification per policy 7.11

2

200

Mark open multi-dose vials with a ___ -day expiration date unless otherwise directed by the manufacturer's instructions.

28

300

Single-dose vials should be discarded ____ after opening.

Immediately 

400

All PRN orders must include a ___ for administration.

Reason; Ex: Tylenol PRN for pain.

500

Be sure all prescription pads and printer prescriptions paper are ____ and _____.

Locked and secured 

Misc.

100

Whose job is it to improve organizational performance?

Everyone's job.

200

What do you do or how do you respond when asked a question by a surveyor and you are unsure of the answer?

_____

300

What does PDCA mean? Harris Health System uses this 4-step process for performance improvement. 

PLAN 

DO

CHECK 

ACT

400

How are incidents reported and who reviews the reports?

Via the electronic incident reporting system (e-IRS) via the intranet. After submission, a follow-up investigation will be conducted by Risk Management/Department of Pharmacy Leadership.