VTH Service Audits

Purpose/ Applicability: The purpose of this document is to outline the process that the Veterinary Teaching Hospital (VTH) Administrative Audit Team will utilize to randomly audit VTH hospital services.

Scope: This SOP applies to all VTH services including, Midwest Equine, VMSC, ambulatory services, and the Wildlife Medical Clinic.

Items for audit include but are not limited to:
- Sampling records for the following:

• Documentation of controlled substances prescribed. This is to ensure that all controlled substances logged as given are documented in a second area of the medical record (e.g. the SOAP note, discharge summary, etc.) (Pharmacist or dispensary staff)
• Controlled substance administration documentation, and applicable witness signatures. This is to ensure that all controlled substances are obtained through appropriate channels with full quantities accounted for through administration or wasting and documented with appropriate witnesses as required by hospital policy (reviewed by Pharmacist or dispensary staff)
  • This includes, but is not limited to, looking at the following as applicable to follow controlled substance chain of custody:
    • Medication Administration Record (purple sheet)
    • EQ Medication Administration Record (pink sheet)
    • Anesthesia Flow Sheet
    • Euthanasia Form (blue sheet)
    • Vial logs (yellow sheets)
    • Sedation Administration and Monitoring Record
    • ICU/ER/IMC flow sheets
    • Cubex logs
    • EMR patient chart
    • Paper waste logs
• Review of ward medications and supplies:
  • Labeling practices (Pharmacist or dispensary staff)
  • Appropriate ward medications and their storage (Pharmacist or dispensary staff)
  • Medications: expired or items nearing expiration (Pharmacist of dispensary staff)
  • Supplies: expired or items nearing expiration (Patient Services Coordinator)
• Review of Facilities:
  • Repair needs (Patient Services Coordinator)
  • Cleanliness of area (including refrigerators) (Patient Services Coordinator)
  • Sharps containers (Patient Services Coordinator)
• Review of Lead
  • Evaluation of all lead PPE to ensure its integrity (Animal Imaging Coordinator)

Timeline: Each hospital service will be audited no less than once per calendar year. A week’s notice of audit will be provided to the service area to ensure appropriate staff is available. Advanced notice may be forgone if circumstances warrant an immediate audit.

Procedure:

1. An Internal scheduled will be developed by the VTH Audit Team.
2. Notification will be provided to the service area one week before the audit.
3. The service head will be provided with this SOP to provide an overview of the audit process.
4. Three records will be selected for each service from the approximately three months preceding the audit. For services that house patients in ICU, at least one record will be a patient that was in ICU. For services that house patients in IMC, at least one record will be a patient that was in IMC. Patient records will be audited through the entirety of the selected visit including any service transfers that may have occurred. The specific records being selected will not be disclosed until after the audit is completed.
5. Record review will be for appropriate controlled substance documentation during the visit selected. All controlled substances charged to the patient will be evaluated to determine that they have corresponding administration documentation, Cubex transactions, and waste logging as necessary based on hospital policy.
6. If requested by the service, audit team members may attend rounds on the day of the audit to explain what is being audited and why as a teaching opportunity.
7. After the audit each team member will provide a written document to the Associate Hospital Director to be compiled with all other findings and shared with the service.
   a. The service head is expected to respond within 1 week of being provided the audit findings indicating how they plan to address each issue, prevent future similar issues and a timeline for correction.
   b. If a response is not received from the service head within 1 week, the report will be elevated to the VTH Hospital Director for response on how the service will address the issues. 
8. The service head’s response to all audit issues will be added to the final audit report and stored in a shared location accessible to all members of the VTH Administrative Audit Team.
9. If follow up or a recheck by the VTH Administrative Audit Team is needed, a time frame of expected follow up will be indicated.
10. When lack of appropriate controlled substance or charge documentation is identified,information will be provided to the staff member supervisor, faculty supervisor and clinical coordinator for informational purposes. For students, the faculty supervisor as well as appropriate educational program supervisor will be notified. Disciplinary action will be pursued if the problem is not corrected.