1. Selection and storage
Look for similar names, strengths or packaging and examine how storage helps staff select the intended product.
Free fillable PDF
Medication Safety Process Check
If the wrong medication reached this point, what would stop it?
Use this two-page tool with pharmacy, nursing and quality to follow a medication through everyday work. Examine the safeguards, look for evidence they work, and agree on what needs to change.
Developed by Julia Dalphin, HACP, founder of True North Readiness.
Your tool is ready
Download the PDF and save a separate copy for each unit or process you review. Open it in a PDF reader that supports fillable forms.
Download the toolWhat you will review
Examine the safeguards in everyday work.
2. Preparation and labeling
Follow medication identity, concentration and route through preparation, interruptions and handoffs.
3. Verification before use
Ask staff to demonstrate checks and explain how discrepancies are resolved before administration.
4. Administration and monitoring
Observe scanning, infusion safeguards and patient monitoring where applicable.
5. Exceptions and interruptions
Discuss overrides, urgent doses, scanning failures and downtime. Find out when the safe process is difficult to follow.
6. Learning and action
Review a recent near miss or workaround, identify what changed and assign a recheck.
How to use it
Follow one medication from selection through administration. Observe routine work and discuss an exception with the people who perform the process. Record the safeguard and evidence observed, then any gap, next action, owner and due date.
Select Observed, Gap, Not verified or N/A in each section. A policy or verbal assurance alone does not demonstrate performance. An observed safeguard reflects this review, not proof of sustained safety.
Who should use this tool?
Pharmacy, nursing and quality leaders working with the clinicians who perform the medication process. Use a separate copy for each unit or process reviewed.
Can I complete it electronically?
Yes. Download the two-page PDF to a reader that supports fillable forms, enter your observations and save a copy. You can also print it.
Is this a comprehensive medication audit?
No. It is a focused discussion and observation aid, not a compliance score or a substitute for clinical judgment and applicable requirements. Do not introduce errors into patient care to test safeguards. Use your local safety escalation process if an immediate hazard is found.