2014 Medication Spotlight Survey

Introduction

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Hospital Information

Hospital name*_________________________________________________

Hospital street address 1*_________________________________________________

Hospital street address 2_________________________________________________

Hospital city/town*_________________________________________________

Hospital state*_________________________________________________

Hospital ZIP code*_________________________________________________

Survey respondent name*_________________________________________________

Survey respondent title*_________________________________________________

Hospital contact telephone number (xxx-xxx-xxxx)*_________________________________________________

Survey respondent email address*_________________________________________________

Section 1: Pharmacy Hours & Medication Order Review/Screening

1.A. Is there a pharmacist on site 24 hours a day, 7 days a week (24x7)?*( ) Yes

( ) No

1.B. Do you plan to have a pharmacist on site 24x7 in the future?*( ) Yes

( ) No

Section 1B: Order Entry & Screening

For the following four questions, which pertain only to inpatient settings, please provide details about how your CPOE system automatically screens and provides prescriber alerts for:

1.B.1.A. Allergies( ) Patient allergy information is visible to prescribers on all medication order entry screens AND the CPOE system automatically screens orders at the time of prescriber order against allergy information to alert prescribers AND requires electronic documentation (not simply acknowledgement) to justify override.

( ) Patient allergy information is visible to prescribers on all medication order entry screens AND the CPOE system automatically screens order at the time of prescriber order against allergy information to alert prescribers but overrides require a simple acknowledgement of having seen the alert.

( ) Allergy alerts are not visible to prescribers or CPOE system does not automatically screen for allergies.

1.B.1.B. Potential drug-drug interactions( ) Clinically significant drug-drug interaction alerts are visible to prescribers on all medication order entry screens at the time of order entry AND the system requires electronic documentation (not simply acknowledgement) to justify override.

( ) Potential drug-drug interaction alerts are visible to prescribers on all medication order entry screens at the time of order entry but overrides require a simple acknowledgement of having seen the alert.

( ) Drug interaction alerts are not visible to prescribers or CPOE system does not automatically screen for potential drug-drug interactions.

1.B.1.C. Therapeutic duplication (note that duplicative medications deemed clinically insignificant by your hospital do not require electronic documentation)( ) Clinically significant therapeutic duplication alerts are visible to prescribers on all medication order entry screens at the time of prescriber order entry AND the system requires electronic documentation (not simply acknowledgement) to justify override. (NOTE: Those duplicative medications deemed by your hospital to be considered clinically insignificant do not require electronic documentation.)

( ) Therapeutic duplication alerts are available to prescribers on all medication order entry screens but overrides require a simple acknowledgement of having seen the alert.

( ) Therapeutic duplication alerts are not visible to prescribers or CPOE system does not automatically screen for therapeutic duplication.

1.B.1.D. Appropriateness of dose range( ) CPOE system automatically screens for appropriateness of dose range information for, at a minimum, all orders for neonatal and pediatric patients, patients with impaired renal function, and patients receiving antineoplastics AND provides visible alerts to prescribers

at the time of order entry AND requires electronic documentation (not simply acknowledgement) to justify override.

( ) CPOE system automatically screens for appropriateness of dose range information on only a portion of the orders for neonatal and pediatric patients, patients with impaired renal function, and patients receiving antineoplastics AND provides visible alerts to prescribers at the time of order entry AND requires electronic documentation (not simply acknowledgement) to justify override.

( ) CPOE system does not automatically screen for appropriateness of dose range for any of the above high-risk categories or overrides require a simple acknowledgement of having seen the alert.

1.B.2. Your hospital’s CPOE is operational and is being used by prescribers for medication order entry for inpatient beds as follows (note that "available inpatient" beds are those beds that are physically available for patients whether or not they are routinely occupied or staffed): *( ) ≥75% of available inpatient beds

( ) 50% - 74% of available inpatient beds

( ) 1% - 49% of available inpatient beds

( ) 0% (system is not operational for any inpatient beds)

1.B.3. For those inpatient beds where CPOE is operational, prescribers directly enter medication orders as follows: *( ) ≥75% of medication orders

( ) 50% - 74% of medication orders

( ) 1% - 49% of medication orders

( ) 0% (no medication orders are entered by prescribers)

1.B.4. Your hospital has fully or partially operationalized a computerized prescriber medication order system that is routinely used by prescribers to directly enter medication for the emergency department. The technology to permit direct prescriber medication order entry is utilized by prescribers to enter (please respond considering use of CPOE in any ER or outpatient unit(s) where prescribers use CPOE systems to enter orders): *( ) ≥75% of medication orders

( ) 50% - 74% of medication orders

( ) 0% - 50% of medication orders

( ) N/A

Section 1: Pharmacy Hours & Medication Order Review/Screening

Section 1C: Order Entry & Screening

Inpatient, non-emergency medication orders routinely are screened by the pharmacist prior to the administration of the first dose, through an automated review, including all medications taken from floor stock or "non-profiled" automated dispensing machines. An "automated review" is one in which rules-based technology is used to screen the order electronically instead of manually. Automated reviews must screen the medication order against the patient profile (including, at a minimum, patient's age, gender, height, weight, allergies, and current medication profile). Automated reviews do not include the use of electronic drug reference databases that require interpretation by the practitioner.

This review may be accomplished by either an on-site pharmacist or an off-site pharmacist with remote access to the hospital computer system for purposes of entering and screening orders. This review applies to both CPOE- and non-CPOE-entered medication orders. The denominator includes all medication orders written 24x7, including medication orders written where there is not a pharmacist on site.

In the following questions, "documented measurement" involves examination or study of a reasonable/sufficient sample of medication orders to determine the percent of inpatient medication orders that are screened by the pharmacist prior to administration of first dose. (For example, a two-week sampling of all medication orders or 4% of all annual new medication orders). Documentation has been retained and is available for review. Documentation can be done retrospectively from existing data. If you have systems that track overrides and all floor stock is contained in profiled automated dispensing machines, you could run a report that measures: # Overrides (numerator) / Total Medication Orders (denominator).

1.C.1. Documented measurement within the past 18 months has demonstrated that:*( ) ≥98% of first dose inpatient orders, excluding emergency situations, has been reviewed by a pharmacist prior to administration of the first dose (note that "emergency situations" are situations in which the clinical status of the patient would be significantly compromised by the delay resulting from a pharmacist's review)

( ) 90% - 97% of first dose inpatient orders, excluding emergency situations, have been reviewed by a pharmacist prior to administration of the first dose

( ) 0% -90% of first dose inpatient orders, excluding emergency situations, have been reviewed by a pharmacist prior to administration of the first dose

( ) No measurement was done or documentation does not exist

1.C.2.A. What percent of non-emergency CPOE and non-CPOE entered orders written in the emergency department are screened by a pharmacist prior to the administration of the first dose, through an automated review, including all medications taken from floor stock or "non-profiled" automated dispensing units?*( ) 75% or more of orders are screened by a pharmacist

( ) 50-74% of orders screened by a pharmacist

( ) 1-49% of orders screened by a pharmacist

( ) No orders are screened

( ) N/A: hospital does not have an emergency department

1.C.2.B. What percent of non-emergency CPOE- and non-CPOE-entered orders written in two or more ancillary areas/units (other than the emergency department) are screened by a pharmacist prior to administration of first dose, through an automated review, including all medications taken from floor stock or "non-profiled" automated dispensing units? This would include areas such as PACU, cath labs, endoscopy, surgery, etc.*( ) 75% or more of orders are screened by a pharmacist

( ) 50-74% of orders screened by a pharmacist

( ) 1-49% of orders screened by a pharmacist

( ) No orders are screened

( ) N/A hospital does not have 2 or more ancillary areas/units

1.C.3. The pharmacist uses an automated system of order screening that screens the new order against a computerized database that includes a listing of the patient's medications and other patient parameters so that (check all that apply):*[ ] Patient allergy information is visible to pharmacists on all medication order entry/review screens AND the system automatically screens orders' allergy information to alert the pharmacist.

[ ] Potential drug-drug interaction alerts are visible to pharmacists on all medication order entry/review screens at the time of order entry.

[ ] Therapeutic duplication alerts are visible to pharmacists on all medication order entry/review screens at the time of order entry.

[ ] The system screens for appropriateness of dose range information for, at a minimum, all orders for neonatal and pediatric patients, patients with impaired renal function, and patients receiving antineoplastics AND alerts the pharmacist at the time of order entry.

[ ] Potential drug-pregnancy/lactation interactions alerts are visible to pharmacists on all order entry/review screens at the time of order entry.

[ ] Potential drug-diagnosis interaction alerts are visible to pharmacists on all order entry/review screens are the time of order entry.

When a pharmacist is not on duty (not simply on call) either on site or off site with remote access to a hospital computer system, inpatient medication orders routinely are screened by a registered nurse through an automated review for drug allergies, drug interactions, therapeutic duplications, and dosing appropriateness prior to the administration of the first dose, including all medications taken from floor stock or "non-profiled" automated dispensing units.

1.C.4. Documented measurement within the past 18 months has demonstrated that:*( ) ≥98% of first dose orders, excluding emergency situations, have undergone an automated review by a registered nurse with demonstrated competency in the medication review process prior to administration of the first dose (note that "emergency situations" are situations in which the clinical status of the patient would be significantly compromised by the delay resulting from an RN review)

( ) 90% - 97% of first dose orders, excluding emergency situations, have undergone an automated review by a registered nurse with demonstrated competency in the medication review process prior to administration of the first dose

( ) 0% - 90% of first dose orders, excluding emergency situations, have undergone an automated review by a registered nurse with demonstrated competency in the medication review process prior to administration of the first dose

( ) No measurement was done or documentation does not exist

( ) N/A - we have 24x7 pharmacist review of orders by either on site pharmacist or remote pharmacist with access to hospital computer system

1.C.5. In the non-CPOE environment, is there an independent interpretation of new inpatient physician orders by both a nurse and a pharmacist?*( ) Yes

( ) No

( ) N/A (CPOE is fully operational)

1.C.6. Are the independent interpretations compared prior to the administration of the first dose?*( ) Yes

( ) No

Section 2: Pharmaceutical Compounding of Sterile Preparations

1. What level of risk, as defined in the USP-NF Chapter 797 on Pharmaceutical Compounding – Sterile Preparations, is your current sterile products compounding?*( ) Low

( ) Medium

( ) High

2. Do you require media fill testing for all employees who prepare sterile medications at a minimum of at initial hire followed by annual testing for low and medium risk compounding and semi-annual for High risk compounding?*( ) Yes

( ) No

3. Do you require gloved fingertip sampling for all employees at initial hire followed by annual sampling for low and medium risk compounding and semi-annual for high risk compounding?*( ) Yes

( ) No

4. Is your compounding environment cleaned as follows:*

Yes No

Hoods: at the beginning of every shift, before each batch, not longer than 30 minutes following previous surface disinfection when ongoing

( ) ( )

compounding activities are occurring, after spills and when surface contamination is known or suspected.

Counters and carts: daily

( ) ( )

Floors: daily ( ) ( )

Shelves and storage bins: monthly

( ) ( )

Walls and ceilings: monthly or use a barrier isolator without a clean room

( ) ( )

5. Do you have systems in place (i.e. policies, inspections) that prevent multiple use vials, except vaccines, being used beyond 28 days after opening?*( ) Yes

( ) No

6. Written competency evaluations exist and are followed by all staff for at a minimum at initial hire followed by annually thereafter. Check all that apply*[ ] Hand Hygiene

[ ] Garbing

[ ] Cleaning and Disinfecting

[ ] Aseptic Technique

7. All supplies introduced into the buffer area, either for storage or immediate compounding, are uncartoned and wiped down with the designated disinfecting agent prior to entry into the buffer area.*( ) Yes

( ) No

8. A line of demarcation in the ante-area or segregated compounding area separates the dirty area from the clean area. *( ) Yes

( ) No

9. Do you use the following appropriate beyond use dates (or stricter) for compounded sterile products?Prepared in an ISO 5 hood in an ISO 7 environment or in an isolator:

Or

Prepared in an ISO 5 hood that is NOT located in a clean room

*( ) Yes

( ) No

10. Do you perform routine monitoring of air pressure differential or airflow in your clean room and/or isolator and record it every shift in a log?*( ) Yes

( ) No

( ) N/A (do not have a clean room or isolators)

11.A. Certification that each ISO classified area (e.g., ISO Class 5, 7 and 8) is within established guidelines is performed no less than every 6 months and whenever the LAFW, BSC, CAI, or CACI is relocated or the physical structure of the buffer room or ante-area has been altered. Testing shall be performed by qualified operators using current, state-of-the-art electronic equipment with results meeting ISO Class 5, 7, or 8 depending on the requirements of the area.*( ) Yes

( ) No

11.B. The above certification includes smoke testing.( ) Yes

( ) No

Section 3: Automated Dispensing Machines

3.A. Does your hospital utilize Automated Dispensing Machines (ADMs) on inpatient units?*( ) Yes – For only controlled substances and floor stock

( ) Yes – For most/all medications, including controlled substances

( ) No

3.B. Do you utilize ADMs on inpatient units, at a minimum, to store controlled substances and/or a limited variety of non-controlled medications primarily intended as starter doses and/or PRN medications?*( ) Yes

( ) No

3.B.1. Is the system "profiled" (i.e., the ADM is interfaced to the main pharmacy database or electronic profile so that medications cannot be removed [without override] until the pharmacist has reviewed, screened, and approved the order and the profiling system is functional 24 hours a day, seven days a week)?*( ) Yes

( ) No

3.B.2. What percentage of medication in the ADM is stored in a separate, locked compartment, so that there is access to only one medication at a time?*( ) ≥90%

( ) 75% - 89%

( ) 50% - 74%

( ) <50%

3.C. Do you utilize ADMs on inpatient units as the primary source of most/all patient medications, including controlled substances and/or a limited variety of non-controlled medications primarily intended as starter doses and/or PRN medications?*( ) Yes

( ) No

3.C.1. Is the system "profiled" (i.e., the ADM is interfaced to the main pharmacy database or electronic profile so that medications cannot be removed [without override] until the pharmacist has reviewed, screened, and approved the order and the profiling system is functional 24 hours a day, seven days a week [in other words, the entire profiling requirement is not disabled for portions of the day])?*( ) Yes

( ) No

3.C.2. What percentage of medication in the ADM is stored in a separate, locked compartment, so that there is access to only one medication at a time?*( ) ≥90%

( ) 75% - 89%

( ) 50% - 74%

( ) <50%

3.D. Is there a systematic process for identifying and physically separating look-alike, sound-alike drugs in matrix drawers?*( ) Yes

( ) No

3.E. In the listing of medication on the screen of the ADM console, do you utilize tall-man letters in medication labeling to avoid mix up of look-alike, sound-alike drugs?*

( ) Yes

( ) No

3.F. In the listing of medication on the screen of the ADM console, do you display warnings or messages about high-alert drugs?*( ) Yes

( ) No

3.G. For hospitals that do not have a pharmacist on duty 24 hours a day, is an ADM used to store an inventory of medications that can be accessed by nursing supervisors or other nursing personnel to meet needs when the main pharmacy is closed?*( ) Yes

( ) No

( ) N/A (pharmacist is on duty 24 hours a day)

3.H. From the following, select the phrase that best describes your system's process for pulling stock from pharmacy inventory and refilling any non-bar-code-assisted ADM refills:*( ) Pharmacist or technician fills independently with no double-check

( ) All refilling is double-checked by pharmacist or technician

( ) N/A all medications placed in ADM's are bar coded

3.I. Do you use bar-code technology to pull stock and refill ADMs?*( ) Yes

( ) No

3.J. What percentage of medications are checked using bar-code technology when pulling medications from stock and refilling ADMs?*( ) ≥ 90%

( ) 50% - 89%

( ) 25% - 49%

( ) < 25%

3.K. Does your hospital use RXCHECK in Pyxis or similar technology to check that high-alert drugs are being filled correctly?*( ) Yes

( ) No

3.K.1. What percentage of hospital-designated high-alert medications are checked by a second individual using RXCHECK or similar technology? *( ) ≥75%

( ) 50% - 74%

( ) 1% - <50%

( ) No high alert medications checked by a second individual

3.L. Are nurses allowed to return medications to their original ADM locations?*( ) Yes

( ) No

Section 4: Bar-Coded Medication Administration Systems

4.A. Do you have a Bar-Coded Medication Administration (BCMA) system in place for inpatients?*( ) Yes

( ) No

4.B. The technology to permit BCMA is in service for what percent of available inpatient beds?*( ) ≥75%

( ) 50% - 74%

( ) <50%

4.C.1. For the following two questions, which pertain to those inpatient beds for which this technology is in service, please provide the percent of medication doses for which . . .

4.C.1.A. The patient identification band is scanned*( ) ≥75%

( ) 50% - 74%

( ) <50%

4.C.1.B. The medication dosage is scanned*( ) ≥75%

( ) 50% - 74%

( ) <50%

4.D. What percent of overrides are reviewed by a pharmacist on a daily basis?*( ) ≥75%

( ) 50% - 74%

( ) <50%

4.E. Are there policies and procedures in place that require the bar-coding of the medication packaging be retained through to the bedside?*( ) Yes

( ) No

Section 5: Smart Pumps

5.A. Do you have a smart pump system available?*( ) Yes

( ) No

( ) N/A

5.B. What percent of pumps within the organization are smart pumps?*( ) ≥ 90%

( ) 50% - 89%

( ) 25% - 49%

( ) <25%

5.C. Of the following 10 common medications, please check all for which you have built libraries and loaded into pumps (check all that apply):[ ] Insulin drips

[ ] Dopamine

[ ] Dobutamine

[ ] Heparin drips

[ ] Oxytocin drips

[ ] Magnesium sulfate drips

[ ] IIb/IIIa inhibitor drips

[ ] Norepinephrine drip

[ ] Nitroglycerin drip

[ ] Diltiazem drip

5.D. Do you have policies requiring standard concentrations of IV infusions of medications that are approved by the P&T Committee and appropriate to your patient populations?*( ) Yes

( ) No

( ) N/A

Section 6: Clinical Pharmacy Services

6.A. Does your pharmacy have a systematic method to identify patients with poor renal function and, in those patients identified with renal function compromise, to review the dosing of drugs for which renal dosing is applicable within 24 hours of starting the drug?*( ) Yes

( ) No

( ) N/A

6.B. Do you have a process to identify patients whose renal function may change during the hospital stay?*( ) Yes

( ) No

( ) N/A

6.C. Do you have a systematic method to identify cachectic patients when calculating an estimated creatine clearance (CrCl)?*( ) Yes

( ) No

( ) N/A

6.D. Does your hospital/pharmacy have in place a systematic method (e.g., an antibiotic stewardship program) that (a) is adequately resourced to track applicable patients on antibiotics and (b) employs reportable process measures to promote the proper use of antimicrobial drugs with the intent to reduce injudicious use of antibiotics, improve patient safety, and reduce the emergence of antibiotic resistant strains of micro-organisms?*( ) Yes

( ) No

6.E. Does your hospital use approved protocols for the initiation and maintenance of anticoagulant therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions?*( ) Yes

( ) No

6.F. Do you have an Oncology Dosing Service that includes pharmacist rounding with a multidisciplinary Oncology team, pharmacist review of appropriateness and dosing, monitoring of laboratory results, and use of a profile or tracking mechanism? (Select N/A if you do not administer any oncology drugs in your hospital.)*( ) Yes

( ) No

( ) N/A: No oncology drugs are administered in your hospital

6.F.1 Does the pharmacist review appropriateness and dosing, monitor laboratory results and use a profile or tracking mechanism for oncology drug therapy?*( ) Yes

( ) No

( ) N/A: No oncology drugs are administered in your hospital

6.G. Does the pharmacist review all Total Parenteral Nutrition (TPN) and Peripheral Parenteral Nutrition (PPN) therapy, including participation in multidisciplinary rounds, daily review and assessment, and routinely making recommendations and interventions. (Check N/A if you do not administer any TPN or PPN therapy in your hospital.)*( ) Yes

( ) No

( ) N/A

6.H. Does your hospital have a pharmacokinetic service whereby pharmacists routinely calculate dose of and monitor at least aminoglycosides and vancomycin?*( ) Yes

( ) No

( ) N/A neither aminoglycosids nor vancomycin are administered at your hospital

Section 7: Planning & Development for Medication Systems (non-scored)

1. Regarding your hospital's planning for CPOE, please indicate your current state of planning and/or implementation:( ) Planning for CPOE

( ) Currently selecting CPOE

( ) Vendor has been selected (training, configuration, and testing under way)

( ) Implementation in progress

( ) Fully implemented

( ) None of the above (please explain): _________________________________________________

Follow-up: What is the date by which your hospital expects to implement CPOE in all inpatient areas?Month:: _________________________________________________

Year:: _________________________________________________

2. Regarding your hospital’s planning for Bar-Coded Medication Administration (BCMA) systems, please indicate your current state of planning and/or implementation:( ) Planning for BCMA

( ) Currently selecting BCMA

( ) Vendor has been selected (training, configuration, and testing under way)

( ) Implementation in progress

( ) Fully implemented

( ) None of the above (please explain): _________________________________________________

Follow-up: What is the date by which your hospital expects to implement BCMA in all inpatient areas?Month:: _________________________________________________

Year:: _________________________________________________

3. Regarding your hospital’s planning for electronic Medication Administration Record (MAR) systems, please indicate your current state of planning and/or implementation:( ) Planning for MAR

( ) Currently selecting MAR

( ) Vendor has been selected (training, configuration, and testing under way)

( ) Implementation in progress

( ) Fully implemented

( ) None of the above (please explain): _________________________________________________

Follow-up: What is the date by which your hospital expects to implement MAR in all inpatient areas?Month:: _________________________________________________

Year:: _________________________________________________

4. Regarding the availability of a remote pharmacist system (i.e., an on-duty pharmacist who is off site but has remote access to the pharmacy computer for purposes of entering

and screening all non-emergency orders), please indicate your current state of planning and/or implementation:( ) Planning for remote pharmacist system

( ) Currently selecting remote pharmacist system

( ) Vendor has been selected (training, configuration, and testing under way)

( ) Implementation in progress

( ) Fully implemented

( ) None of the above (please explain): _________________________________________________

Follow-up: What is the date by which your hospital expects to implement remote pharmacist services in all inpatient areas?Month:: _________________________________________________

Year:: _________________________________________________

5. Are there any other initiatives are you currently planning and developing that we may have failed to ask you about?____________________________________________

____________________________________________

____________________________________________

____________________________________________

6. What system/vendor and software version are you using for medication order entry?____________________________________________

____________________________________________

____________________________________________

____________________________________________

7. What system/vendor and version of Automated Dispensing Machines are you using?____________________________________________

____________________________________________

____________________________________________

____________________________________________

8. Please select the statement below that best describes your hospital’s current use of robotics in preparation of intravenous medications:( ) We are currently using robotics

( ) The funding for robotics has been approved, and we are planning implementation within the next 12 months

( ) We are including robotics in our long-term planning

9. Please select the statement below that best describes your hospital’s current use of bar-code technology and scanning in the preparation of intravenous medications:( ) We are currently using bar-code technology and scanning

( ) The funding for bar-code technology and scanning has been approved, and we are planning implementation within the next 12 months

( ) We are including bar-code technology and scanning in our long-term planning

10. Please indicate whether a pharmacist is pre-production checking AND/OR post-production checking the preparation/compounding of the following high-risk intravenous medications. Select N/A if you do not prepare or compound these intravenous medications at your hospital or if you use pre-mixed products only.

Chemo TPN

Concentrated

Electrolytes

Pediatric Medication

s

Intrathecal or

EpiduralOther

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Pre-Production

( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

Post-Production

( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

Section 8: Clinical Pharmacy Services (un-scored section)

1. Please place a checkmark next to each of the clinical services that are provided routinely at your institution AND give a brief description of the services and the hours in which they are provided. This is a non-scored section in 2013, and information will be used to develop potential questions for future surveys.

Clinical Service

(check if routinely provided at your

hospital)

Brief Description

& Measurement

of Service

Hours/Days Service

Available (Mon. -

Fri.)

Hours/Days Service

Available (Sat. - Sun.)

Clinical Service

(check if routinely provided at your

hospital)

Systematic review of all patients for DVT prophylaxis by a pharmacist or in conjunction with a pharmacist

[ ] ___ ___ ___

Pharmacokinetics Service and monitoring of "high-risk" medications (e.g., amino glycosides)

[ ] ___ ___ ___

Pharmacy participation in multidisciplinary rounds and/or decentralized pharmacy services

[ ] ___ ___ ___

Pharmacy discharge counseling on target medications and disease states

[ ] ___ ___ ___

2. Please list any clinical pharmacist specialists on your staff:____________________________________________

____________________________________________

____________________________________________

____________________________________________

3. If you provide care for a neonatal population and currently use heparin flushes for catheter patency, do you dispense only in a prefilled syringe?( ) Yes

( ) No

( ) N/A

Follow-up: Comments:____________________________________________

____________________________________________

____________________________________________

____________________________________________

4. If vincristine is used in your organization, do you prepare the medication by dilution in a minibag of IV fluids verses dispensing in a syringe?( ) Yes

( ) No

( ) N/A

Follow-up: Comments:____________________________________________

____________________________________________

____________________________________________

____________________________________________

Relative to the Medication Reconciliation function:5. Who performs medication histories? [ ] Pharmacist

[ ] Pharmacy Technician

[ ] Physician

[ ] Physician Assistant/Nurse Practitioner

[ ] Nurse

[ ] Pharmacy Student

[ ] Other

Follow-up: Which department or service is responsible for the accuracy and completeness of this function?_________________________________________________

Relative to the Medication Reconciliation function:6. Who performs medication reconciliation on admission? [ ] Pharmacist

[ ] Pharmacy Technician

[ ] Physician

[ ] Physician Assistant/Nurse Practitioner

[ ] Nurse

[ ] Pharmacy Student

[ ] Other

Follow-up: Which department or service is responsible for the accuracy and completeness of this function?_________________________________________________

Relative to the Medication Reconciliation function:7. Who performs medication reconciliation on discharge? [ ] Pharmacist

[ ] Pharmacy Technician

[ ] Physician

[ ] Physician Assistant/Nurse Practitioner

[ ] Nurse

[ ] Pharmacy Student

[ ] Other

Follow-up: Which department or service is responsible for the accuracy and completeness of this function?_________________________________________________

Relative to the Medication Reconciliation function:8. Who performs medication teaching on discharge? [ ] Pharmacist

[ ] Pharmacy Technician

[ ] Physician

[ ] Physician Assistant/Nurse Practitioner

[ ] Nurse

[ ] Pharmacy Student

[ ] Other

Follow-up: Which department or service is responsible for the accuracy and completeness of this function?_________________________________________________

Relative to the preparation of IV solutions: 9. Do you use bar coding technology in the preparation of IV solutions? ?( ) Yes

( ) No

Relative to the preparation of IV solutions: 10. Do you use robotics in the preparation of IV solutions? ?( ) Yes

( ) No

11. Does a pharmacist routinely participate in multidisciplinary rounds in your IUCs?( ) Yes

( ) No

( ) N/A hospital does not have any ICUs

12. Does your hospital offer on-site pharmacist services within the Emergency Department?( ) Yes

( ) No

( ) N/A hospital does not have an Emergency Department

Follow-up: If yes, please enter the hours of service here:_________________________________________________

Attestation

I hereby certify that the information provided in this survey is accurate to the best of my knowledge and I understand that the Maine Health Management Coalition will use this information to create public reports designed to assist consumers in their evaluation of health care services. I also understand that employers and their health plans / claims administrators may use this information in designing benefits packages and hospital reimbursement agreements.*[ ] I have read the above attestation and agree by its terms

Date:*_________________________________________________

Review

Thank You!