HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure the consultant pharmacist evaluates the performance and competency of drug room personnel who provide pharmacy services when the consultant pharmacist is not on the premises and assures that all outdated, mislabeled or otherwise unusable drugs are not available for patient use. Two (D & E) of two drug room personnel files reviewed did not contain evidence of orientation to the drug room, performance evaluations, or job descriptions for the drug room. Expired drugs were observed on drug room shelves available for patient use.

Findings:

1. Two 5ml ( milliliter ) bottles of Bromonidine Tartrate 0.15% ophthalmic solution ( Exp. 11/11), two bottles of carbamide proxide 6.5% ear drops ( Exp. 10/11), one box plus several loose vials of Heparin 1000u/ml (Exp. 4/11) and Dexamethasone 4mg/ml one ml vials (Exp. 4/11 ) were expired.

2. Drug room staff D, who was working while the fulltime drug room person was on vacation stated on 07/18/12 that she had not been formally oriented to the drug room.