Independent Double Check Audit Tool for High Alert Medications - Non IV


Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?


Verifying Clinician (First name Last Name)

Administration clinician obtains medication and any appropriate supplies for administration

Administration clinician prints Omnicell label

Administration clinician and verifying clinician pull up medication order

Administration and verifying clinician calculate weight based or unit based dosing independently (if applicable)

Administration and verifying clinician ensure dose is within safe dose range per approved reference

Verifying clinician checks the medication label to the order independently

Administration and verifying clinician validate the medication is being administered at the appropriate time against a valid document (i.e. order, eMAR, etc.), including the last dose delivered

Administration and verifying clinician validate the medication is being administered through the right route. Note order has intended oral route (PO, NG, NJ, etc.), if applicable.

Administration clinician prepares the medication dose and form for administration if Pharmacy doesn't provide the medication already prepared and labeled.

Administration clinician checks the medication label to order independently

Administration clinician verifies the medication expiration date.

Administration and verifying clinician sanitize hands and don new gloves.

Performed at the bedside 


Administration and verifying clinician scan band on the patient

Performed at the bedside 


Administration and verifying clinician visually confirm right patient by matching 2 patient identifiers between the screen and the ID band.

Performed at the bedside 


Administration clinician scans the medication.

Performed at the bedside 


Administration and verifying clinician independently verify the label matches the order for the right medication, right concentration, right dose, and right route.

Performed at the bedside 


Administration clinician selects "complete" and administers medication

Performed at the bedside