8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 1/24
VOLUME 2
January 2008
5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA Tel +1 (610) 825-6000 Fax +1 (610) 834-1275 Web www.ecri.org E-mail [email protected]
Medication Safety
Self-Assessment QuestionnaireSelf-Assessment Questionnaires 10
Continuing CareRisk Management
Initial assessment by: Date:
In consultation with:
Date of previous
assessment:
Medication safety is a top priority for long-term care facilities, and the reasons are clear: the harm to residents from
medication errors is great, the cost of such errors to society is high, and accrediting organizations, federal agencies,
and third-party payers expect facilities to adopt the numerous strategies currently available to prevent medica-
tion errors. Therefore, reducing the frequency and severity of medication errors and adopting strategies to prevent
adverse drug events are ongoing goals for facilities. Because medication errors can involve many groups—
physicians, nurses, pharmacists, and even self-medicating residents—risk managers must help their facilities
adopt a multidisciplinary approach to medication error reduction.
The Continuing Care Risk Management (CCRM) System has prepared this Self-Assessment Questionnaire (SAQ)to help risk managers evaluate their facilities’ policies and procedures regarding medication safety. Although
extensive, this SAQ does not address all the medication management issues that accrediting organizations and state
and federal regulations may require facilities to address. CCRM recommends that this questionnaire be completed
initially to acquire baseline data and periodically thereafter to assess progress.
Some of the resources used in the development of this SAQ are included in the list preceding the assessment
questions. This list of resources is not intended to be comprehensive, but it does reflect important standards,
guidelines, and other documents that underlie various questions. For example, medication safety agencies, such as
the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia (USP), have contributed extensively to
the field of medication safety and are cited here. For additional information, refer to the Risk Analysis “Medication
Safety” in the Patient/Resident Care section of the CCRM System.
42 CFR § 483.25 (2000).•American Nurses Association (ANA). 2007 study of injectable medication errors [online]. [cited 2007 Jul 16].•
Available from Internet: http://www.nursingworld.org.
American Society of Consultant Pharmacists (ASCP):•
Drug regimen review [online]. [cited 2007 Jul 20]. Available from Internet: http://www.ascp.com/resources/drr.—
Guidelines on preventing medication errors in pharmacies and long-term care facilities through reporting and ⎯
evaluation [online]. 1997 Jul [cited 2007 Jul 17]. Available from Internet: http://www.ascp.com/resources/
policy/upload/Gui97-Med%20Errors.pdf.
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 2/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 20082
Self-Assessment Questionnaires 10
Statement on preventing medication errors in pharmacies and long-term care facilities [online]. 1997 Jul [cited—
2007 Jul 20]. Available from Internet: http://www.ascp.com/resources/policy/upload/Sta97-Med%20Errors.pdf.
American Society of Health-System Pharmacists (ASHP):•
ASHP guidelines on preventing medication errors with antineoplastic agents.— Am J Health Syst Pharm 2002 Sep
1;59(17):1648-68.
The medication-use-system safety strategy (MS— 3). Introduction and task analysis [online]. 2001 [cited 2007 Jun13]. Available from Internet: http://www.ashp.org/s_ashp/bin.asp?CID=1001&DID=6347&DOC=FILE.PDF.
Commission on Accreditation of Rehabilitation Facilities—Continuing Care Accreditation Commission•
(CARF-CCAC). 2006 CARF-CCAC ASPIRE to excellence standards manual with survey preparation questions. July 1,
2006—June 30, 2007. Washington (DC): CARF-CCAC; 2006.
Institute for Safe Medication Practices (ISMP):•
Intimidation: practitioners speak up about this unresolved problem [online]. ISMP Med Saf Alert 2004—
Mar 11 [cited 2007 Aug 31]. Available from Internet: http://www.ismp.org/newsletters/acutecare/
articles/20040311_2.asp.
ISMP’s list of high-alert medications [online]. [cited 2007 Jun 11]. Available from Internet: http://www.ismp.—
org/Tools/highalertmedications.pdf.Medication safety contest winner. Policy for a non-punitive, system-based error reporting program. Frederick—
Memorial Hospital, Frederick, Maryland [online]. ISMP Med Saf Alert 2004 Mar 11 [cited 2007 Jun]. Available
from Internet: http://www.ismp.org/Tools/FrederickReporting.asp.
Pharmacy interventions: part II from ISMP survey.— ISMP Med Saf Alert 2002 Jul 10;7(14):1-2.
Institute of Medicine (IOM).• Preventing medication errors. Committee on Identifying and Preventing Medication
Errors. Washington (DC): National Academies Press; 2007.
Joint Commission:•
Comprehensive accreditation manual for long-term care: official handbook. ⎯ Oakbrook Terrace (IL): Joint Commission
Resources; 2005-2006.
Sentinel event statistics—March 31, 2007 [online]. [cited 2007 Aug 29]. Available from Internet: http://www. ⎯
jointcommission.org/SentinelEvents/Statistics.
Joint Commission Resources (JCR):•
Accreditation issues for risk managers. Oakbrook Terrace (IL): JCR; 2004. ⎯
Medication station: conducting FMEA for medication management [online]. [cited 2007 Jun 12]. Available ⎯
from Internet: http://www.jcrinc.com/6629.
Kohn LT, Corrigan JM, Donaldson MS, eds.• To err is human: building a safer health system. Washington (DC):
National Academies Press; 1999.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):•
Statement from NCC MERP: use of medication error rates to compare health care organizations is of no value ⎯
[online]. [cited 2007 Jul 11]. Available from Internet: http://www.nccmerp.org/council/council2002-06-11.html.
What is a medication error? [online]. [cited 2007 Jun 4]. Available from Internet: http://www.nccmerp.org/ ⎯
aboutMedErrors.htm.
National Quality Forum (NQF). Safe practices for better healthcare. 2006 update [consensus report]. Washington•
(DC): NQF; 2006.
U.S. Government Accountability Office (U.S. GAO). Assisted living: quality-of-care and consumer protection•
issues in four states. GAO/HEHS-99-27. Washington (DC): GAO; 1999.
U.S. Pharmacopeia (USP):•
Examining medication errors that occur in the resident’s home. USP Resident Safety CAPSLink [online]. 2004 ⎯
Mar [cited 2007 Jun 28]. Available from Internet: http://www.usp.org.
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 3/24
CONTINUING CARE RISK MANAGEMENT Self-Assessment Questionnaires 10
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 3
Improving the safety of automated dispensing devices. USP Resident Safety CAPSLink [online]. 2007 Jan ⎯
[cited 2007 Jun 18]. Available from Internet: http://www.usp.org.
Medication errors frequently asked questions [online]. [cited 2007 Jul 16]. Available from Internet: ⎯
http://www.usp.org.
Leadership
1. Does the governing body receive periodic
reports on medication safety activities
and initiatives?
2. Do the medical director, director of
nursing, and facility administrator dem-
onstrate support for medication safety?
3. Do those in leadership, managerial, or
supervisory roles demonstrate com-
mitment to a “just culture,” in which
reported errors are viewed as an oppor-
tunity for systems evaluation and
improvement?
4. Is leadership support for the prevention
of medication errors demonstrated by
a. allocation of resources needed to
assess, plan for, implement, and
monitor safe-drug-use systems in the
institution?
b. implementation of policies and
systems that support medication
error and near-miss reporting in a
fair and just environment?
c. provision of feedback to caregivers
on how error and near-miss
reporting has resulted in system
improvements to prevent recurrence
and unsafe processes?
d. establishment of a medication safety
recognition program whereby those
who report unsafe medication
practices and/or are involved in
reducing potential medication errors
are rewarded for their efforts?
e. discouragement of institutional
environments in which open
communication is inhibited and/or
intimidation prevails?
*N/I stands for “Needs Improvement.”
YES NO N/I* N/A COMMENTS
(continued
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 4/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 20084
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
5. Are caregivers encouraged to question
or clarify potentially unsafe medication
orders without fear of retribution, intimi-
dation, or disrespect? 5.1. Do facility administrators consider the
identification and correction of such an
intimidating environment a high priority?
6. Does leadership support the preven-
tion of medication errors by conducting
walkarounds in resident care areas?
6.1. On these walkarounds, is information
about unsafe practices solicited from
frontline clinicians and caregivers?
6.2. Do these walkarounds result in periodicfeedback from leadership to frontline cli-
nicians regarding the steps being taken to
improve medication safety?
7. Does the risk manager work with the
facility’s administrators, clinicians, and
educators to promote effective communi-
cation among caregivers involved in the
medication management process?
Policies and Procedures
8. Are policies related to medication safety
created by multidisciplinary teams
including representation from nursing,
medical, pharmacy, risk management,
and quality improvement staff?
9. Do the facility’s medication safety poli-
cies and procedures comply with state
and federal regulations and address
a. resident-specific information?
b. selection and procurement?
c. storage?
d. ordering and transcription?
e. preparation and dispensing?
f. administration?
g. monitoring?
h. high-risk medications?
i. evaluation?
j. reporting of errors and near misses?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 5/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 5
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
10. Do these policies and procedures also
a. establish who may administer
medications, consistent with
applicable laws and regulations?
b. provide criteria for determining
what medications are made available
for dispensing or administration?
c. define a process for handling drug
shortages?
d. define a process for approving and
procuring new medications?
e. address the use of multiuse vials
and describe the steps necessary to
prevent vial contamination?
11. Do the policies specify medication ad-
ministration procedures that include
a. the use of two unique identifiers for
resident identification?
b. verification of drug and dose?
c. independent checks for dose
calculation when applicable?
d. verification of the route of
administration?
12. Does the facility have a method to track
compliance with its policies?
Storage
13. Are medications stored in a secure man-
ner to prevent unauthorized access?
14. Are look-alike/sound-alike drugs stored
in a segregated manner to prevent acci-
dental interchange?
15. Does the facility conduct an annual reviewof identified look-alike/sound-alike drugs
and strategies used to prevent accidental
interchange of the drugs?
16. Are stored drug concentrations limited
and standardized?
17. Have concentrated electrolytes been
removed from resident care areas?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 6/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 20086
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
18. Are periodic pharmacy inspections
conducted
a. to evaluate drug stock and
maintenance of emergencymedications and supplies?
b. to evaluate storage of medications
that residents bring into the facility?
19. Do the facility’s procedures for the safe
storage and handling of medications
include the following:
a. Standardized methods for labeling,
packaging, and storing medications?
b. A requirement that medications
remain labeled until they areadministered to residents?
c. Routine pharmacy review of
automated or nonautomated
dispensing cabinets and unit stock
to identify and dispose of expired,
damaged, or contaminated medications?
d. Segregation of expired, damaged, or
contaminated medications until they
are removed from the facility?
e. Use of TALLman* lettering?
20. Are the following steps taken to mini-
mize the risks of mix-ups of different
strengths of the same medication:
a. Purchase of different strengths of
the same medication from different
suppliers to avoid similarities in
packaging and labeling?
b. Separate storage of different
strengths of the same medication?
c. Use of warning labels on different
strengths of the same medication to
alert users to the potential for mix-ups?
Medication Ordering and Transcription
21. Do all orders and transcriptions for medi-
cation specify a diagnosis, condition, or
indication?
* TALLman lettering is the practice of highlighting sections of drug names using uppercase letters. Examples include DOBUTamine/DOPamineand vinBLASTine/vinCRISTine.
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 7/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 7
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
22. Are medication orders clearly written
and accurately transcribed?
23. Does the facility communicate to care-
givers and have written policies and
procedures to address the specific ele-
ments of a complete medication order?
Illegible Handwriting, Verbal or TelephoneOrders, and Abbreviations
24. When an order is ambiguous, incomplete,
irregular, or illegible, are nurses and
pharmacists required to contact the pre-
scribing physician and ask for clarification?
24.1. Does the facility prohibit the filling ofsuch orders until clarification is obtained?
25. Does the facility’s leadership help foster a
culture in which professionals do not feel
intimidated about questioning orders or
pressured into carrying out questionable
orders?
26. Are policies regarding verbal and tele-
phone orders in compliance with state
and federal regulations and accreditation
standards?
27. Does the facility have a policy and proce-
dure in place for taking telephone orders?
27.1. Is the identity of a prescriber giving a
telephone order verified to ensure that
he or she is an authorized prescriber?
27.2. Is the identity of the resident verified
using two unique identifiers before tele-
phone orders are accepted for the resident?
28. Is an order written or keyed directly into
the resident’s medical record as it is being received?
28.1. Does the person taking the order read it
back verbatim to the prescriber to verify
what was written in the medical record?
28.2. Is the information entered into the resi-
dent’s medical record signed and dated
by the person taking the order?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 8/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 20088
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
28.3. Does the prescriber verify, sign, and date
the order within a specified time frame?
29. Does the facility maintain a list of pro-
hibited abbreviations, acronyms, and
symbols that are known to increase the
risk of miscommunication and dosage
errors (e.g., the use of “U” for units and
“qd” for daily)?
29.1. In preparing the list of prohibited abbre-
viations, acronyms, and symbols, has the
facility reviewed recommendations of
prohibited abbreviations from organiza-
tions such as ISMP, NCC MERP, and
the Joint Commission?
29.2. Does the facility require clinicians to
avoid using prohibited abbreviations in
their medication orders and other resi-
dent-specific documentation?
29.3. Does the facility have mechanisms in
place to ensure clinicians’ compliance
with the list of prohibited abbreviations
(e.g., provision of feedback to a practitio-
ner if a prohibited abbreviation is used)?
29.4. When an unacceptable abbreviation
is used for a medication order, do
responsible staff members (e.g., nurses,
pharmacists) verify the order with the
prescriber before it is filled?
Medication Preparation and Dispensing
30. Are all medication orders reviewed by a
pharmacist before medication is removed
from stock or an automated storage and
distribution device?
30.1. If a pharmacist is not available, are
licensed independent practitioners (LIPs)
allowed to control the ordering, prepara-
tion, and administration of medication?
30.2. If the situation is urgent and a delay
would harm the resident, are LIPs
allowed to control the ordering, prepara-
tion, and administration of medication?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 9/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 9
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
30.3. Are these reviews conducted in a manner
that does not unduly delay administra-
tion of medication?
30.4. If a pharmacist is not available to reviewa medication, does the pharmacist review
these orders as soon as possible once the
pharmacy reopens?
30.5. Is the pharmacist’s review of the medica-
tion order documented in the resident’s
record?
31. Are sterile medication and intravenous
admixtures prepared in the pharmacy?
32. Are there provisions for obtaining medi-
cations when the pharmacy is closed?
33. Is there a process in place for handling
recalled and discontinued drugs?
34. Is there a process in place for handling
drugs that are returned to the pharmacy?
35. Is standardized labeling used?
36. Are there labeling specifications in
place for
a. medications that are prepared but
not immediately administered?
b. individualized medications for
multiple specific residents?
37. Is a drug history (including prescription
and over-the-counter medications, vita-
mins and nutritional supplements, herbal
and alternative medications, and home
remedies) obtained and documented for
all residents upon admission?
37.1. Is a complete list of the resident’s cur-
rent (home) medications obtained upon
admission or entry to the facility? 37.2. Is resident compliance with the medi-
cation regimen (as indicated by the
medication list) assessed (i.e., is the resi-
dent taking the medications as prescribed)?
37.3. Are medications that are ordered for the
resident compared to the home list (recon-
ciled), and are any discrepancies resolved?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 10/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200810
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
37.4. Is the current medication list updated
when medication reconciliation is
completed?
38. Are measures in place to prevent medi-cations from being dispensed before a
resident’s allergies have been identified
and documented?
Medication Administration
39. When conducting an assessment of
a resident’s medication practices, do
caregivers
a. identify all medication-taking
behaviors?
b. evaluate the success of the
medication regimen?
c. detect the presence and risk of
adverse medication effects?
d. educate the resident or family
members on medication regimens?
e. assess the resident’s medication-
taking behaviors, including daily
medication regimen (e.g., timeliness);
whether he or she is taking any other
treatments, using other remedies,or taking a different individual’s
prescription; and when and where
prescriptions are filled?
f. assess the resident’s comprehension
of the medication, including what
symptoms led the healthcare
provider to prescribe it and what the
medication is for, when to take it,
and when to refill the prescription?
g. request that the resident or family
members bring all of his or hermedications to the location where
the medication regimen assessment
takes place?
40. Is the following resident information
available to caregivers who are adminis-
tering medications:
a. Age?
b. Sex?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 11/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 11
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
c. Current medications?
d. Diagnoses?
e. Conditions and comorbidities?
f. Relevant laboratory values?
g. Allergies and sensitivities?
h. Other information as appropriate
such as weight and height?
41. Are residents’ identities consistently veri-
fied before medication is administered?
41.1. Are at least two unique resident identi-
fiers (e.g., name, medical record number)
used to verify resident identity?
41.2. Does the facility prohibit caregivers fromusing the resident’s room number as a
resident identifier?
42. Do caregivers who administer
medications
a. verify that the medication selected
for administration is correct when
checked against the medication order
and the medication label?
b. ensure medication integrity by visual
inspection and by a check of theexpiration date?
c. verify that there are no
contraindications?
d. ensure that the medication is
administered at the right time, in the
prescribed dose, and via the right route?
e. educate the resident and/or family
about potential adverse reactions
and instruct them to watch for these
reactions?
f. communicate any concerns aboutthe medication to the resident’s
physician or other providers
and resolve any problems before
administering the medication?
g. notify prescribers in accordance with
policies and procedures in the event
of an adverse reaction?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 12/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200812
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
43. When using multiuse vials, do caregivers
a. read the label to ensure that the
vial contains a preservative and is
multiuse and that the expiration date
has not passed?
b. inspect the vial for any discoloration,
turbidity, particulate matter, or
precipitates and discard the vial if
there is any evidence of contamination?
c. follow hand hygiene practices before
beginning the task?
d. clean the stopper with 70% alcohol
before a needle or other device isinserted?
e. use only sterile needles or other
devices (e.g., spike) to access the vial?
f. avoid touching the stopper?
g. store the vial in a secure refrigerator
after it is opened?
Medication Monitoring
44. Are caregivers monitored through direct
observation or other means periodically
during medication preparation, dispens-
ing, and administration for compliance
with facility policies?
45. Are caregivers required to monitor the
effects of medications on residents?
46. Are caregivers required to take into
account the resident’s perceptions about
efficacy or side effects of medication?
High-Risk Medications
47. Does the facility have a process in place
to identify high-risk or high-alert medica-
tions, which have a higher risk of causing
errors or other adverse outcomes or a
narrow margin of safety (e.g., insulin,
opiates and narcotics, anticoagulants,
concentrated electrolytes)?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 13/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 13
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
48. Has the facility implemented strategies
such as the use of preprinted orders,
safety checklists, and independent
double checks to support the safe use ofhigh-risk or high-alert medications?
49. Is there a management process to pre-
vent the occurrence of errors and critical
events involving these medications?
50. Are there special procedures for handling
high-risk medications (e.g., heparin,
warfarin, insulin, potassium chloride
injection concentrate, narcotics and
opiates) throughout all steps in the medi-
cation process?
51. Do safety protocols for high-alert medica-
tions include the following:
a. Use of warning labels and cautionary
messages on computer screens?
b. Independent verification of the drug
against the order?
c. Prompt removal of discontinued
drugs and solutions and return to
the pharmacy?
Medication Safety Strategies
52. Has a baseline assessment been conducted
to help the facility focus medication
improvement efforts on identified
priorities such as medication event
identification and reporting, high-alert
medications, medication safety education,
and the elimination or reduction of dan-
gerous abbreviations and verbal orders?
53. Is there a process in place to review rec-
ommendations related to medication
safety from external sources and agencies
(e.g., American Society of Consultant
Pharmacists, American Medical Directors
Association, ECRI Institute, ISMP, Joint
Commission, National Quality Forum,
USP) on a regular basis?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 14/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200814
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
53.1. Is there a process to implement recom-
mendations from outside agencies that
are appropriate for the facility?
53.2. If recommendations are not adopted, are
the reasons documented?
54. Are policies and procedures in place to
address medication recalls or discontinu-
ations by manufacturers or the U.S. Food
and Drug Administration (FDA)?
55. Have medication management processes
throughout the facility been proactively
assessed for the following risk points:
a. Availability of resident information
for the prescriber to consider whenordering drug therapy?
b. Access to current drug information,
contraindications, and potential
interactions?
c. Communication of medication
regimens during resident transfer?
56. Have technological interventions such as
the following been considered as preven-
tion strategies:
a. Computerized provider order-entrysystems?
b. Bar-coding systems?
c. Decision support systems?
d. Pharmacy information systems?
57. If a decision is made to use technological
interventions, does the facility
a. set clear objectives and goals for the
system and identify baseline data
to measure goal achievement after
implementation?
b. include all caregivers involved in
medication management when
assessing the role of technology in
the current medication-use process?
c. match the technology to the
workflow process when possible but
modify the work process in order
to capitalize on the technology’s
advantages and safeguards?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 15/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 15
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
d. develop a detailed flowchart of
the medication-use process and
determine workflows before and
after implementing the technology?
e. use human factors analysis
techniques in the implementation
of new technologies to reduce
workarounds used because of a
poor system/user fit?
f. provide users with training and
education about the new system
and its appropriate use?
g. emphasize teamwork and effective
communication among caregivers?
58. Are automated dispensing units (ADUs)
used as part of an overall automated
medication management system that
generally requires pharmacy review and
order entry before caregivers can remove
drugs from the device?
59. Has a standardized process been devel-
oped for selecting drugs stocked in the
dispensing units relative to where these
devices are located in the facility?
59.1. Are the specific needs of individual
resident care units considered when
inventories are defined?
60. Have maximum dose ranges for “high
alert” medications been established, and
are these values visible on the dispensing
units as a ready reference?
61. Is the importance of removing only a
single dose (unit of use) of medication
ordered stressed to caregivers?
61.1. Are caregivers instructed to return any
unused drugs to the pharmacy as soon
as possible and not to place them back in
the ADU?
62. Is stocking and restocking of medications
in ADUs evaluated by on-site or consul-
tant pharmacy staff for accuracy?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 16/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200816
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
63. Is staff competency in performing inde-
pendent checks (double checks) for all
high-alert medications—even if bar-code
bedside scanning is in place—reviewed?
64. Have nontechnical interventions, includ-
ing the following, been considered as
prevention strategies:
a. Using system analysis to identify
and mitigate risks associated with
medication use?
b. Fostering a culture of safety?
c. Improving error detection and
reporting?
d. Reconciling resident medications?
e. Improving communication among
those involved in the medication-use
process?
65. Does the facility have a medication safety
system in place that
a. provides comprehensive reference
material concerning medications and
related health data that is readily
accessible to providers?
b. communicates resident-specific
medication-related information
in an interoperable format?
(Interoperability is defined as the
ability of information to be easily
aggregated, stored, displayed in a
single view, and shared.)
c. assesses the safety of medication
use through active monitoring and
uses the monitoring data to improve
implementation of prevention strategies?
d. includes plans to implement
electronic prescribing?
e. subjects prescriptions to evidence-
based, current clinical decision-
support recommendations?
f. requires caregivers to possess
appropriate competencies for each
step of the medication-use process?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 17/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 17
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
g. reviews in an ongoing process
potential drug hazards identified by
patient safety organizations?
Medication Reconciliation
66. Is there a protocol in place that requires
verification of residents’ medications
upon admission, during transfer from
one level of care to another, and at
discharge?
67. Is there an effective system in place that
facilitates communication with acute
care providers and other care providers
so that an accurate list of medications istransmitted among them as a resident
moves through different levels of care?
68. Are residents provided with an accurate
list of medications when they leave
the facility?
Standardization
69. Is the process for prescribing, preparing,
dispensing, and administering medica-
tions standardized?
70. Are the facility’s preprinted medication
order forms or computerized forms
standardized?
71. Are established dosing protocols used?
72. Are medications available in ready-to-
administer form?
73. Are dangerous abbreviations, symbols,
and drug dose designations forbidden?
74. Is medical equipment such as infusionpumps and other medication delivery
devices standardized across the facility?
Role of the Pharmacist
75. Do the facility’s policies and procedures
address the pharmacist’s role in the med-
ication process?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 18/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200818
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
75.1. Is the pharmacist’s role in the medication
process consistent with state and
federal laws?
76. Does the facility’s pharmacist conduct
reviews of drug regimens on a
monthly basis?
76.1. Are drug regimens reviewed more fre-
quently than every 30 days when the
resident’s condition warrants it?
76.2. Do drug regimen reviews include an
assessment of the number of medications
and drug classes as well as potential
drug/drug interactions?
76.3. Do drug regimen reviews include anassessment for potentially inappropriate
medications for the elderly, in accordance
with the Beers* criteria and/or the Cen-
ters for Medicare & Medicaid Services
State Operations Manual?
77. Do the facility’s pharmacists
a. promote the development and use
of medication error identification,
reporting, and evaluation systems?
b. participate in the examination
and evaluation of the causes of
medication errors?
c. educate caregivers about medication
errors and methods of prevention?
d. recommend strategies for system
changes to prevent medication errors?
e. cooperate in reporting relevant
medication errors to a national
system for review, analysis, and
development of recommendations to
reduce and prevent medication errors?
Education
78. Does caregiver and leadership education
address the Joint Commission’s National
Patient Safety Goals and medication-
safety-related recommendations from
patient safety organizations?
* For a list of drugs, see: Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997 Jul 28;157(14):1531-6
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 19/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 19
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
79. Are educational programs developed to
heighten caregiver and provider aware-
ness of medication policies and procedures?
80. Are educational sessions provided to
caregivers when new drugs or new drug
delivery systems are introduced?
81. Do caregivers have access to drug infor-
mation regarding medications on their
units as well as information on the error
potential and safety and efficacy of these
medications?
81.1. If yes, are procedures in place to remove
outdated materials?
82. Do pharmacists provide caregivers withinformation on rarely used drugs that
have been ordered for a resident?
83. Do educators review with caregivers
through initial and ongoing education
a. the common types and causes
of medication errors, using case
studies as examples?
b. the importance of timeliness and
thorough reporting of medication
events and near misses?
c. the importance of clarifying unclear
orders?
84. Is specific education provided on safe
medication practices that target high-
alert medications such as insulin and
warfarin?
85. Are new personnel educated in the use of
the facility’s medication event reporting
system?
85.1. Are personnel provided periodicrefresher training on the facility’s event
reporting system?
86. Is medication safety information offered
to physicians or other prescribers of med-
ications to the facility’s residents?
87. Is medication safety included in resident
and family education?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 20/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 200820
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
88. Does the facility provide residents and/
or families written educational informa-
tion in language they can understand to
promote medication safety upon admis-sion and at discharge?
89. Does resident education include a “teach
back” component to assess the resident’s
level of understanding about medications?
Medication Event Reporting
90. Are caregivers given clear definitions of
actual and potential medication errors
and specific instructions on how to report
a medication event, a near miss, or an
unsafe situation that could lead to a med-ication error?
91. Are caregivers instructed to submit an
event report even if an error was cor-
rected before it could affect a resident?
92. Are caregivers instructed to preserve
any relevant packaging, tubing, or other
material that may be important in ana-
lyzing the cause of an error?
93. Are caregivers instructed not to specu-
late why an error occurred and to avoidrecording speculative remarks in the
resident’s chart?
94. When a medication error occurs, does
the risk manager work with caregivers to
identify how best to disclose the informa-
tion to residents and/or families?
95. Does the facility have a policy on disclo-
sure of errors or adverse events?
95.1. Do caregivers comply with this policy
when a medication error has occurred?
96. If a medication error occurs, does the facility
a. support those involved in the error
with counseling?
b. conduct a systems analysis of the
incident?
c. report the incident to appropriate
outside groups as may be required
by law?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 21/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 21
(continued
Self-Assessment Questionnaires 10
YES NO N/I N/A COMMENTS
97. When a medication error involving a
device results in death, serious illness,
or serious injury to the resident, does the
facility report the event to FDA? 98. Does the medication event reporting sys-
tem facilitate the collection of data that
allows classification of events by type of
error, step in the medication-use process,
and other event details such as location
and time of the event?
99. Is there a process in place to categorize
medication errors based on severity level?
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 22/24
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 23/24
CONTINUING CARE RISK MANAGEMENT
©2008 ECRI Institute. May be reproduced by member institution only for distribution within its own facility. JANUARY 2008 23
Self-Assessment Questionnaires 10
Corrective Action Form
MEDICATION SAFETY
Assessment Completed By: Date:
QUESTIONNO. ACTION REQUIRED RESPONSIBILITY
TARGETDATE
ACTION COMPLETED
DATE INITIALS
8/13/2019 Sample CCRM Medication Safety SAQ
http://slidepdf.com/reader/full/sample-ccrm-medication-safety-saq 24/24
CONTINUING CARE RISK MANAGEMENT
QUESTIONNO. ACTION REQUIRED RESPONSIBILITY
TARGETDATE
ACTION COMPLETED
DATE INITIALS
Self-Assessment Questionnaires 10
Top Related