29. Pharmacy Emergency Preparedness Plan MM.10.

4
30. Hazardous Materials Management Plan FMS.14.6
Ordering and Prescribing
31. Policy and Procedures for Prescribing Medications MM.20.1
32. Policy and Procedures on Specific Types of Medication MM.21.1
Orders
33. Policy and Procedures on Prescribing Privileges MM.19.1
34. Guidelines on Antibiotics Prescribing MM.22.1
35. Policy for Prescribing Non-formulary Medications MM.24.1
36. Policy and Procedures on Prescribing Formulary MM.24.2
Medications for Off-label Indications.
37. Policy for Telephone and Verbal Orders MM.23.1, MM.23.3, QM.25.1, QM.25.2,
MM.23.4, QM.25.3
38. List of Approved and Prohibited Abbreviations and Symbols MOI.7.1, MOI.7.2, MOI.7.3, MOI.7.4,
MOI.7.5
Preparing and Dispensing
39. Aseptic Technique and IV Admixture Manual MM.26.1
40. Policy on Preparation and Dispensing of TPN. MM.27.1, NICU.12.6
41. Guidelines on Stability and Compatibility of TPN MM.27.8
42. Policy for Preparation and Dispensing of Chemotherapy. MM.28.1
43. Policy for Non-sterile Pharmaceutical Compounding MM.29.1
44. Policy for Obtaining Medications After Working Hours MM.33.1
45. Policy for Handling Recalled, Discontinued and Damaged MM.34.1
Medications
Drug Administration
46. Document that defines nurses and other clinical staff MM.36.1
authorized to administer medications
47. Policy for Medication Verification before Administration MM.37.1
48. Policy for Monitoring Patient Response to Medications MM.39.1
Drug Monitoring
49. Policy for Handling Adverse Drug Reactions (ADRs) Reports MM.40.1, MM.40.2
50. Policy for Handling Medication Errors, Near-misses, and MM.41.1, MM.41.2
Hazardous Situations
51. Medication Errors Reporting System MM.41.5
Contracted Services
52. TPN Outsource Contract and Contract Service Monitoring MM.27.9
53. Chemotherapy Outsource Contract and Contract Service MM.28.16
monitoring
54. Extemporaneous Preparations Outsource Contract and MM.29.6
Contract Service Monitoring
Drug Formulary
55. Hospital Drug Formulary MM.8.1, MM.8.4, MM.8.5, MM.8.6,
MM.8.7, MM.8.8, MM.8.9

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 Medication Management Surveyor (Units Documents)
Required Documents Related Standards
Inpatient/Outpatient Pharmacy
1. Patient Medication Profile MM.25.1, MM.31.6
2. Extemporaneous Preparations Manual MM.29.4
(Formulation Book)
3. Extemporaneous Preparations Log Book MM.29.5
4. Outpatient Education Materials MM.35.2
Pharm Admin/QI
5. Pharmacy Department Organization Chart MM.2.1
6. Non-formulary Drug Request Form MM.9.2, MM.24.3, MM.24.5
7. Policy for Floor Stock Medications Assignment MM.11.13
8. Floor Stock Inspection Records MM.11.13
9. Reports of Medication Quality to Saudi FDA MM.11.15
10. Crash Cart Check Sheet MM.15.7
11. Un-approved Indication Request Form MM.24.4, MM.24.5
12. Pharmacy Monthly Inspection of Nursing Units MM.26.13
Performing IV Admixture.
13. Pharmacy Monthly Evaluation of Nursing Staff MM.26.14
Performance of IV Admixture
14. List of Approved Medications to be Accessible to MM.33.3
Non-pharmaceutical Staff
15. Pharmacy On-call Schedule MM.33.4
16. Drug Recall File MM.34.2
17. ADR file and Analysis of ADR Reports MM.40.7
18. Medication Errors Reporting System MM.41.7
19. Root-cause Analysis of Significant Medication MM.41.8
Errors
20. Reports of Serious ADRs to Saudi FDA MM.40.9
21. Reports of Sentinel Events MM.41.12
22. Internal Disaster Plan (pharmacy preparedness FMS.17.2
plan)
23. Departmental Meeting Minutes LD.18.2
24. Departmental Indicators Report LD.31.3
25. Performance Improvement Projects/Reports LD.31.4
26. Periodic Departmental Performance LD.31.6
Improvement Reports
27. Information System Downtime Procedures and MOI.9.1
Forms
IV Clean Room
28. Parenteral Drugs Stability and Compatibility MM.26.11
Guidelines
29. Hospital Guidelines on Safe Recycling of Un-used MM.26.15
Sterile Compounded Preparations

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30. Operational Efficiency and Maintenance MM.30.7
Certificate of LAFH
31. Cleaning Schedule MM.30.8
Chemotherapy
32. Chemotherapy Stability and Compatibility MM.28.10
Guidelines
Hospital-wide
33. Temperature Log Sheets (refrigerators, freezers, MM.11.9, MM.12.4, MM.12.8
etc.)
34. List of Hazardous Medications And Chemicals MM.13.2
35. Hazardous Materials Management Plan FMS.14.2
36. Pharmacy Interventions for Incomplete, Illegible, MM.20.7
or Unclear Orders
Hospital-wide - Crash Cart
37. Crash Cart Medication Management System MM.15.6
38. Crash Cart Check Sheet PC.31.3, PC.31.4, PC.31.5
Hospital-wide - High Alert/LASA
39. Evidence of Implementation of Standard MM.5.4
Concentrations of IV Infusions
40. Staff education material and attendance record MM.6.3
for LASA medications
Hospital-wide - Narcotics
41. Narcotics Documents for Inventory, MM.18.4, MM.18.5, MM.36.5
Endorsement and Accountability

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6. Laboratory Surveyor (Closed Session)
- Laboratory Organization Structure
1. 1 Laboratory scope of services LB.1.1, LB.1.2, LD.28.1, LD.28.2
2. 2 Laboratory organizational chart LB.1.5, LD.26.1, LD.26.2
3. 3 Departmental Meeting Minutes LD.18.2
4. Internal Disaster Plan FMS.17.2
Laboratory Customer Focus
5. Departmental Scope of Services LD.27.1
6. Interdepartmental Agreement LD.27.2
7. Point-of Care-Testing program LB.28.1
8. Assignment POCT coordinator LB.28.2
9. Blood Supply/Exchange Agreements LB.62.1
10. Laboratory policy on Turn Around Time LB.19.1
11. Evidence of establishing TAT in agreement with all LB.19.2
relevant clinical departments
Laboratory Facilities and Safety Program
12. Laboratory safety and infection control manual LB.17.1,FMS.14.6, FMS.15.1
13. Laboratory safety and infection control training LB.17.2
program
14. Laboratory policy and procedures on monitoring LB.17.3
the safety and infection control
Laboratory Personnel
15. Departmental Request for Resources and Staffing LD.30.1
16. Departmental Staffing Plan LD.30.2
17. Laboratory/facility policy on job description and LB.3.1, LD.30.3
samples of job descriptions (lab staff)
18. Policy for Delegation of Authority LD.17.2
19. Laboratory training and competency assessment LB.5.1
program
Laboratory Purchasing and Inventory
20. Laboratory policy and procedure on receipt LB.6.1
inspection and testing of materials/services
21. Laboratory policy and procedure on tracking and LB.6.2
inventory management of supplies and reagents
22. Laboratory policy and procedure on reagents and LB.7.1
solutions labeling
23. Laboratory policy and procedure on supplies and LB.7.2
reagents storage
24. Laboratory policy and procedures on water types LB.7.3
25. Laboratory policy and procedures on reference LB.27.1
laboratory services
Laboratory Equipment
26. List of Essential Medical Supplies and Devices LD.23.1
27. Laboratory/Facility Policy and/or process LB.8.1
description on critical equipment selection

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