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Run: High-Alert Medication Independent Double-Check SOP

Use this SOP to run an independent double-check for high-alert medications before dispensing or administration. It helps the team verify the order, dose, pro...

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Steps

The first actor verifies that the medication is included on the facility high-alert list and that the current workflow requires an independent double-check.
The first actor compares the active order to the patient profile and confirms the patient identifiers, medication name, strength, dose, route, frequency, and scheduled time.
The first actor independently calculates the dose, confirms the concentration and formulation, and checks the expiration date and package integrity without relying on the second actor's calculation.
The second actor independently reviews the order, performs the calculation or product verification without seeing the first actor's result, and confirms the same medication details.
The actors compare results for patient identity, medication, dose, concentration, route, timing, and documentation. If any mismatch exists, they stop and escalate.
The first actor records the completed independent double-check in the approved system, including both verifier names or identifiers, date, time, medication details, and any required notes.
The first actor stops the process, isolates the medication if needed, and escalates the discrepancy to the designated pharmacist, prescriber, charge nurse, or supervisor for resolution.

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