Independent Double Check Audit Tool for High Alert Medications - IV


Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?


Verifying Clinician (First Name Last Name)

Administration clinician and verifying clinician obtain medication and pull up medication order

Administration clinician and verifying clinician independently calculate weight based or unit based dosing (if applicable) and ensure within safe dose range per approved reference.

Administration clinician and verifying clinician independently check medication label to order.

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

Once validated, the primary or secondary RN dons appropriate PPE for medication & primes tubing.

Administration and verifying clinician sanitize hands and don new gloves and gown, if indicated.

Performed at the bedside 


Administration clinician scans band on patient and visually confirms right patient by matching 2 patient identifiers between the screen and the ID band.

Performed at the bedside 


Verifying clinician independently compares the confirmation screen to the Pt ID band. Reads and confirms 2 patient identifiers.

Performed at the bedside 


Administration clinician scans the medication label and verifies that this is the correct medication and concentration.

Performed at the bedside 


Verifying clinician documents date, start time, stop time, and co-signs medication.

Performed at the bedside 


Administration clinician resets the "infused totals" on the infusion pump to zero and programs the pump per order.

Performed at the bedside 


Administration clinician compares order view, to medication label, to pump settings: Drug, Dose (no need to do a second ingredient check for TPN), Route, Volume/Infuse Time. * Do not load the medication into the pump until fully verified.

Performed at the bedside 


Verifying clinician independently compares order, to medication label, to pump settings.

Performed at the bedside 



Administration clinician loads pump.

Performed at the bedside 


Administration clinician attaches medication to the patient, label at the patient, and trace lines from bag to the patient.

Performed at the bedside 


Verifying clinician verifies medication is attached (independently traces lines).

Performed at the bedside 


Administration clinician selects "complete" and starts pump.

Performed at the bedside