from the wards by entering orders into CPOE system, which includes decision support and standardized order sets
3.23 6.44 87.1 3.23
58. Medications/medication devices are ordered from the wards verbally (face-to-face), by phone, fax, mail only in a case of emergency
38.71 3.23 58.06 0
59. Medications/medication devices are ordered from the wards by pharmacists
16.13 0 83.87 0
60. Verbal or telephone orders are never accepted for oral or parenteral chemotherapeutic agents, incl. chemotherapeutic agents used for non- oncologic indications
9.68 0 80.65 9.67
61. When verbal or telephone/mail orders must be taken, the orders are immediately transcribed by the pharmacist and then sent to the prescriber for verification
32.26 29.03 32.26 6.45
62. Medications are not removed from inpatient unit stock before a pharmacist review the specific patient order and screens/take a copy of order for safety
9.68 12.9 51.61 25.81
63. Medications are not removed from outpatient4
unit stock before a pharmacist review the specific patient order and screens/take a copy of order for safety
9.68 3.23 61.28 25.81
administration are electronic
65. MARs are available during the selection/ preparation of the medications and at the patient’s bedside
51.61 12.9 29.03 6.46
66. IV and epidural infusion/medication doses are standardized in the standard order sets and MARs (e.g. mg/kg, mcg/kg/min, etc.)
12.9 25.81 54.84 6.45
67. Preprinted order forms for commonly encountered diseases states, procedures or specific drugs (e.g. NTI drugs, second-line drugs) are used to guide the use of drugs
38.71 22.58 25.81 12.9
68. Pharmacy interventions regarding potentially harmful medication order are immediately communicated to the nurses/prescribers to halt the potential administration while awaiting clarifying of the order
45.16 35.48 12.9 6.46
69. In non-urgent situations, off-label drug orders and orders for drugs in atypical doses are checked and approved by the pharmacists
0 12.9 67.75 19.35
70. In urgent situations, there is a formal checking system conducted by the pharmacist for off-label drug orders and orders for drugs in atypical doses
0 9.68 70.97 19.35
71. Cancer chemotherapy orders are verified by the pharmacist for the appropriateness of the ordered medicine, dose, dilution method, administration route and schedule, premedication and auxiliary medication to treat ADEs associated with chemotherapy
0 3.23 74.19 22.58
72. Elements of the high-alert drugs (e.g. chemotherapy) orders are evaluated in the context of established protocols and the patient height, BW, BSA and laboratory parameters of renal and liver impairment
0 3.23 74.19 22.58
73. Time for order verification is consistent and depends on urgency
3.23 64.51 29.03 3.23
74. A designated pharmacist, with a postgraduate qualification, is authorized to prescribe any licensed medicine for any medical condition within his/her competence, with exception of controlled drugs
12.9 16.13 67.74 3.23
75. A designated pharmacist, with a postgraduate qualification, is authorized to prescribe therapeutic substitution
3.23 35.48 58.06 3.23
C. SUPPLY, STORAGE, LABELING, DISTRIBUTION AND ADMINISTRATION
in all medications purchasing
77. At a minimum, pharmacists are involved in all medication devices purchasing and replacement decision
93.55 6.45 0 0
78. The pharmaceuticals are supplied via public tendering procedures
93.54 3.23 0 3.23
79. Pharmacy and Therapeutic committee consisted of one pharmacist at least decides for acquisition of drugs and medication devices
35.48 38.71 16.13 9.68
80. An initial risk assessment is performed to
determine the various types of medication device, identify the possible difficulties in their utilization and address process changes that need to be made and this assessment is updated prior to the purchase of any new medication device
9.68 9.68 41.94 38.70
81. Pharmacists participate in planning of annual budget for acquisition of drugs and medication devices and they are informed about the budget allocated and the dynamic of expenditures
67.74 6.45 22.58 3.23
82. All drugs are stored in designated areas within the hospital pharmacy which are sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security
32.26 64.52 0 3.23
83. Medicines are stored in and dispensed from automatic storage and distribution devices
3.23 3.23 43.83 45.16
84. Alcohol and flammables are stored in areas that meet, at a minimum, basic local building code requirements for the storage of volatiles
3.26 80.61 9.68 6.45
85. Pharmacy and/or ward stocks are reviewed at least annually to determine low usage
medications that may be eligible for removal from inventory
64.52 35.48 0 0
86. Drugs stocked in wards are carefully selected by considering the needs of each patient care ward and unit stock is reviewed every day
58.06 41.94 0 0
87. Drugs stocked in wards are available in the least number of doses, concentrations, and forms that will meet essential patient needs between replenishment (not to exceed 72 h)
41.94 51.61 0 6.45
88. Solutions, drugs, supplies and equipment used to prepare or administer sterile products are stored in accordance with the manufacturer or
Pharmacopoeia requirements
48.39 22.58 9.68 19.35
89. Temperatures in refrigerators and freezers used to store ingredients and finished sterile preparations are monitored and documented daily
ranges and provide immediate problem
notification are used for refrigerators that store critical, temperature-sensitive medications and SOP for how to handle any breach have been developed and followed
91. The packages and labels of new drugs are examined before use and compared to other products to identify any potential for confusion
77.42 12.9 9.68 0
92. Products with similar names and packaging are segregated and not stored alphabetically and the place where the products are relocated is clearly marked
61.29 32.26 6.45 0
93. Auxiliary warnings or specific labels are used on packages and storage bins of drugs with similar names, packages and labels
12.8 41.94 41.94 3.23
94. Bulk chemicals used in the pharmacy are labeled with contents, the date the product was first opened and the expiration date
74.19 25.81 0 0
95. All large-volume bags and bottles of irrigation solutions, organ storage solutions and sterile water are packed, stored and labeled in a way that clearly differentiates them from solution that are administered parenterally
67.74 29.03 3.23 0
96. At a minimum, all medication containers taken to the bedside or use (e.g. syringes, vials and
ampoules, etc.) are labeled with at least the drug name and strength/concentration
22.58 9.68 48.39 19.35
97. Unit oral doses (patient specific oral medications) remain in the original (manufacturer’s) packaging up to the point of actual drug administration at the bedside so the drug is checked for compliance with the MAR
22.58 29.03 29.03 19.35
98. Doses that require less than a full dosage unit (e.g. tablet) are repacked by the pharmacy into unit-dose package
20.9 12.9 46.85 19.35
99. Machine readable codes are used for labeling of commercial drugs and medicinal products prepared in the pharmacy and they are used in the drug distribution system
11,11 11,11 11,11 66,67
100. The central pharmacy has unit-dose distribution system
3.23 0 96.77 0
101. The pharmacy uses robotic packaging/ distribution system
0 0 100 0
102. Oral liquid medications are dispensed from the central pharmacy to patient care units (e.g. for pediatric patients) in ready-to-use patient specific
103. Parenteral medications are dispensed from the central pharmacy to patient care units in ready- to-use patient specific doses (e.g. single unit-of- dose syringes)
16.13 0 83.87 0
104. Vials of concentrated electrolytes are distributed to authorized patient care units only and stocked in limited quantities in secure storage areas
41.94 6.45 48.38 3.23
105. Before drug administration to ensure patient
identification and other essential steps in medication administration barcode readers are used (bar-code-assisted dispensing system)
0 0 93.55 6.45
106. High-alert drugs used within the hospital are identified, error-reduction strategies have been established for these drugs and these have been communicated to all practitioners who
prescribe, dispense and administer the products and monitor their effects
0 12.9 70.97 16.13
107. Double check process before medication administration is a standard practice
9.68 35.48 51.61 3.23
108. There is a standardized procedure for dispensing chemotherapy for the same procedure (e.g. dispensing intrathecal chemotherapy on different days or times from other chemotherapy)
3.23 6.45 54.84 35.48
109. When using i.v. administration devices,
administration rates are regularly calculated and checked
29.04 12.9 35.48 22.58
110. When using NTI drugs, dosage regimens are regularly calculated taking into account the individual PK parameters and TDM data
9.68 19.35 48.39 22.58
111. Double check when calculations are necessary is a standard practice
9.68 9.68 64.52 16.12
112. There is a practice to validate mathematical skills of the pharmacists responsible for calculations (e.g. dosage, concentration, infusion rate, etc.)
6.45 6.45 61.29 25.81
113. Electronic infusion control device (EICD) is used for solution delivery and criteria have been established to determine which patient populations, specific medications and infusion rate require EICD.
6.45 6.45 61.29 25.81
114. Concentrations for infusion of all drugs are standardized, for all patient groups, to a single concentration that is used in at least 90% of the cases
51.61 6.45 41.94 0
115. “Smart” pumps that include drug libraries with pre-established dose and rate limits based on standard concentration are implemented in drug
116. Identification labels on tubing near the insertion site are used to prevent misconnections
9.68 19.35 48.39 22.58
117. Specially designed oral syringes are available in the pharmacy and are used for administering oral/enteral liquid medications
16.13 9.68 51.61 22.58
118. Enteral feeding catheters that cannot connect with i.v. or other parenteral lines are used
70.97 3.23 12.9 12.9
119. Self-administration of drugs by patients is permitted only when specifically authorized by the treating or ordering physician; provided the patient has been educated and trained in the proper manner of self-administration and there is no risk of harm to the patient
22.58 45.16 19.36 12.9
120. All patients are routinely provided with all necessary medications when discharged from hospital
9.68 35.48 38.71 16.13