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Hospitalswill ensure qualified & competent staff. Staff Defined: Paid employees, leased/contracted persons, students & volunteers. Qualified Defined: Person who has met the requirements for a specific position by education, training, experience, licensure, or certification. Qualified Competent Pharmacy Staff
Evidenced By Processof on-going skill/competency assessment. Opportunitiesfor education and development. Periodicperformance review. Provisionof specialized training, education, and skill development for specific tasks or positions. Orientation on general and department measures.
Citations Reflect Failure to establish staff competency standards. Failureto ensure that licensed, certified or registered staff practice only within their scope practice. Failureby a hospital to provide and document staff competency for duties.
Pharmacy: Prepare, Dispense, Administration Requirement that hospitals assure that patient pharmaceutical needs are met in a planned and organized manner. Hospitalscomply with the Board of Pharmacy regulations for a hospital pharmacy license.
Citations Reflect Failureto have an organized, systematic pharmacy service. Failureto have clear orders for medications. Failureto monitor medication effectiveness or therapeutic levels. Failureto review and assure pharmacy approval of medication protocols.
Failure to authenticate medication orders according to policy. Failure to monitor for, remove outdated medications. Failure to label medications in syringes. Failure to keep medications secure according to hospital policy.