Medication Safety Imprest Systems

Level *

Ground (Djarlma)
Level 1 (Galup)
Level 2 (Kep)
Level 3 (Djinda)

Name *

First

Last

Date / Time

Date

Time

Imprest

	Meets requirement	Does not meet requirement	Within Date	Expired Stock	Supply Issue
Aspirin 300 mg (#10#24)	Meets requirementAspirin 300 mg (#10#24) Meets requirement	Does not meet requirementAspirin 300 mg (#10#24) Does not meet requirement	Within DateAspirin 300 mg (#10#24) Within Date	Expired StockAspirin 300 mg (#10#24) Expired Stock	Supply IssueAspirin 300 mg (#10#24) Supply Issue
Baclofen 10 mg (#50#500)	Meets requirementBaclofen 10 mg (#50#500) Meets requirement	Does not meet requirementBaclofen 10 mg (#50#500) Does not meet requirement	Within DateBaclofen 10 mg (#50#500) Within Date	Expired StockBaclofen 10 mg (#50#500) Expired Stock	Supply IssueBaclofen 10 mg (#50#500) Supply Issue
Buscopan 10 mg (#10#20)	Meets requirementBuscopan 10 mg (#10#20) Meets requirement	Does not meet requirementBuscopan 10 mg (#10#20) Does not meet requirement	Within DateBuscopan 10 mg (#10#20) Within Date	Expired StockBuscopan 10 mg (#10#20) Expired Stock	Supply IssueBuscopan 10 mg (#10#20) Supply Issue
Clonazepam 0.5mg (#20#100)	Meets requirementClonazepam 0.5mg (#20#100) Meets requirement	Does not meet requirementClonazepam 0.5mg (#20#100) Does not meet requirement	Within DateClonazepam 0.5mg (#20#100) Within Date	Expired StockClonazepam 0.5mg (#20#100) Expired Stock	Supply IssueClonazepam 0.5mg (#20#100) Supply Issue
Clonazepam 0.5mg (#TMPBG100)	Meets requirementClonazepam 0.5mg (#TMPBG100) Meets requirement	Does not meet requirementClonazepam 0.5mg (#TMPBG100) Does not meet requirement	Within DateClonazepam 0.5mg (#TMPBG100) Within Date	Expired StockClonazepam 0.5mg (#TMPBG100) Expired Stock	Supply IssueClonazepam 0.5mg (#TMPBG100) Supply Issue
Clonazepam 2 mg (#20#100)	Meets requirementClonazepam 2 mg (#20#100) Meets requirement	Does not meet requirementClonazepam 2 mg (#20#100) Does not meet requirement	Within DateClonazepam 2 mg (#20#100) Within Date	Expired StockClonazepam 2 mg (#20#100) Expired Stock	Supply IssueClonazepam 2 mg (#20#100) Supply Issue
Clonazepam 2mg (#TMPBG200)	Meets requirementClonazepam 2mg (#TMPBG200) Meets requirement	Does not meet requirementClonazepam 2mg (#TMPBG200) Does not meet requirement	Within DateClonazepam 2mg (#TMPBG200) Within Date	Expired StockClonazepam 2mg (#TMPBG200) Expired Stock	Supply IssueClonazepam 2mg (#TMPBG200) Supply Issue
Clonidine 100 mcg (#10#50)	Meets requirementClonidine 100 mcg (#10#50) Meets requirement	Does not meet requirementClonidine 100 mcg (#10#50) Does not meet requirement	Within DateClonidine 100 mcg (#10#50) Within Date	Expired StockClonidine 100 mcg (#10#50) Expired Stock	Supply IssueClonidine 100 mcg (#10#50) Supply Issue
Coloxyl and Senna (#10#90)	Meets requirementColoxyl and Senna (#10#90) Meets requirement	Does not meet requirementColoxyl and Senna (#10#90) Does not meet requirement	Within DateColoxyl and Senna (#10#90) Within Date	Expired StockColoxyl and Senna (#10#90) Expired Stock	Supply IssueColoxyl and Senna (#10#90) Supply Issue
Diazepam 5 mg (#25#50)	Meets requirementDiazepam 5 mg (#25#50) Meets requirement	Does not meet requirementDiazepam 5 mg (#25#50) Does not meet requirement	Within DateDiazepam 5 mg (#25#50) Within Date	Expired StockDiazepam 5 mg (#25#50) Expired Stock	Supply IssueDiazepam 5 mg (#25#50) Supply Issue
Diazepam 5 mg (#TMPBG250)	Meets requirementDiazepam 5 mg (#TMPBG250) Meets requirement	Does not meet requirementDiazepam 5 mg (#TMPBG250) Does not meet requirement	Within DateDiazepam 5 mg (#TMPBG250) Within Date	Expired StockDiazepam 5 mg (#TMPBG250) Expired Stock	Supply IssueDiazepam 5 mg (#TMPBG250) Supply Issue
Ibuprofen 200 mg (#24#96)	Meets requirementIbuprofen 200 mg (#24#96) Meets requirement	Does not meet requirementIbuprofen 200 mg (#24#96) Does not meet requirement	Within DateIbuprofen 200 mg (#24#96) Within Date	Expired StockIbuprofen 200 mg (#24#96) Expired Stock	Supply IssueIbuprofen 200 mg (#24#96) Supply Issue
Lactulose	Meets requirementLactulose Meets requirement	Does not meet requirementLactulose Does not meet requirement	Within DateLactulose Within Date	Expired StockLactulose Expired Stock	Supply IssueLactulose Supply Issue
Loperamide 2mg (#20#40)	Meets requirementLoperamide 2mg (#20#40) Meets requirement	Does not meet requirementLoperamide 2mg (#20#40) Does not meet requirement	Within DateLoperamide 2mg (#20#40) Within Date	Expired StockLoperamide 2mg (#20#40) Expired Stock	Supply IssueLoperamide 2mg (#20#40) Supply Issue
Lorazepam (#20#100)	Meets requirementLorazepam (#20#100) Meets requirement	Does not meet requirementLorazepam (#20#100) Does not meet requirement	Within DateLorazepam (#20#100) Within Date	Expired StockLorazepam (#20#100) Expired Stock	Supply IssueLorazepam (#20#100) Supply Issue
Lorazepam (#TMPBG20)	Meets requirementLorazepam (#TMPBG20) Meets requirement	Does not meet requirementLorazepam (#TMPBG20) Does not meet requirement	Within DateLorazepam (#TMPBG20) Within Date	Expired StockLorazepam (#TMPBG20) Expired Stock	Supply IssueLorazepam (#TMPBG20) Supply Issue
Lithium Carbonate 250 mg (#25#200)	Meets requirementLithium Carbonate 250 mg (#25#200) Meets requirement	Does not meet requirementLithium Carbonate 250 mg (#25#200) Does not meet requirement	Within DateLithium Carbonate 250 mg (#25#200) Within Date	Expired StockLithium Carbonate 250 mg (#25#200) Expired Stock	Supply IssueLithium Carbonate 250 mg (#25#200) Supply Issue
Methadone 5mg / 1 ml (#50#200)	Meets requirementMethadone 5mg / 1 ml (#50#200) Meets requirement	Does not meet requirementMethadone 5mg / 1 ml (#50#200) Does not meet requirement	Within DateMethadone 5mg / 1 ml (#50#200) Within Date	Expired StockMethadone 5mg / 1 ml (#50#200) Expired Stock	Supply IssueMethadone 5mg / 1 ml (#50#200) Supply Issue
Metoclopromide 10 mg /1 ml (#3#10)	Meets requirementMetoclopromide 10 mg /1 ml (#3#10) Meets requirement	Does not meet requirementMetoclopromide 10 mg /1 ml (#3#10) Does not meet requirement	Within DateMetoclopromide 10 mg /1 ml (#3#10) Within Date	Expired StockMetoclopromide 10 mg /1 ml (#3#10) Expired Stock	Supply IssueMetoclopromide 10 mg /1 ml (#3#10) Supply Issue
Metoclopromide 10 mg (#10#50)	Meets requirementMetoclopromide 10 mg (#10#50) Meets requirement	Does not meet requirementMetoclopromide 10 mg (#10#50) Does not meet requirement	Within DateMetoclopromide 10 mg (#10#50) Within Date	Expired StockMetoclopromide 10 mg (#10#50) Expired Stock	Supply IssueMetoclopromide 10 mg (#10#50) Supply Issue
Movicol (#10#30)	Meets requirementMovicol (#10#30) Meets requirement	Does not meet requirementMovicol (#10#30) Does not meet requirement	Within DateMovicol (#10#30) Within Date	Expired StockMovicol (#10#30) Expired Stock	Supply IssueMovicol (#10#30) Supply Issue
Mylanta (#50#500)	Meets requirementMylanta (#50#500) Meets requirement	Does not meet requirementMylanta (#50#500) Does not meet requirement	Within DateMylanta (#50#500) Within Date	Expired StockMylanta (#50#500) Expired Stock	Supply IssueMylanta (#50#500) Supply Issue
Olanzepine 5mg (#7#28)	Meets requirementOlanzepine 5mg (#7#28) Meets requirement	Does not meet requirementOlanzepine 5mg (#7#28) Does not meet requirement	Within DateOlanzepine 5mg (#7#28) Within Date	Expired StockOlanzepine 5mg (#7#28) Expired Stock	Supply IssueOlanzepine 5mg (#7#28) Supply Issue
Paracetamol 500 mg (#24#100)	Meets requirementParacetamol 500 mg (#24#100) Meets requirement	Does not meet requirementParacetamol 500 mg (#24#100) Does not meet requirement	Within DateParacetamol 500 mg (#24#100) Within Date	Expired StockParacetamol 500 mg (#24#100) Expired Stock	Supply IssueParacetamol 500 mg (#24#100) Supply Issue
Paracetamol 500 mg (#TMPBG500)	Meets requirementParacetamol 500 mg (#TMPBG500) Meets requirement	Does not meet requirementParacetamol 500 mg (#TMPBG500) Does not meet requirement	Within DateParacetamol 500 mg (#TMPBG500) Within Date	Expired StockParacetamol 500 mg (#TMPBG500) Expired Stock	Supply IssueParacetamol 500 mg (#TMPBG500) Supply Issue
Quetiapine 25mg (#30#120)	Meets requirementQuetiapine 25mg (#30#120) Meets requirement	Does not meet requirementQuetiapine 25mg (#30#120) Does not meet requirement	Within DateQuetiapine 25mg (#30#120) Within Date	Expired StockQuetiapine 25mg (#30#120) Expired Stock	Supply IssueQuetiapine 25mg (#30#120) Supply Issue
Quetiapine 100mg (#30#90)	Meets requirementQuetiapine 100mg (#30#90) Meets requirement	Does not meet requirementQuetiapine 100mg (#30#90) Does not meet requirement	Within DateQuetiapine 100mg (#30#90) Within Date	Expired StockQuetiapine 100mg (#30#90) Expired Stock	Supply IssueQuetiapine 100mg (#30#90) Supply Issue
Quetiapine XR 50mg (#20 #60)	Meets requirementQuetiapine XR 50mg (#20 #60) Meets requirement	Does not meet requirementQuetiapine XR 50mg (#20 #60) Does not meet requirement	Within DateQuetiapine XR 50mg (#20 #60) Within Date	Expired StockQuetiapine XR 50mg (#20 #60) Expired Stock	Supply IssueQuetiapine XR 50mg (#20 #60) Supply Issue
Salbutamol Inhaler (#1#2)	Meets requirementSalbutamol Inhaler (#1#2) Meets requirement	Does not meet requirementSalbutamol Inhaler (#1#2) Does not meet requirement	Within DateSalbutamol Inhaler (#1#2) Within Date	Expired StockSalbutamol Inhaler (#1#2) Expired Stock	Supply IssueSalbutamol Inhaler (#1#2) Supply Issue
Sodium valproate 200 mg (#20#100)	Meets requirementSodium valproate 200 mg (#20#100) Meets requirement	Does not meet requirementSodium valproate 200 mg (#20#100) Does not meet requirement	Within DateSodium valproate 200 mg (#20#100) Within Date	Expired StockSodium valproate 200 mg (#20#100) Expired Stock	Supply IssueSodium valproate 200 mg (#20#100) Supply Issue
Sodium valproate 500 mg (#20#100)	Meets requirementSodium valproate 500 mg (#20#100) Meets requirement	Does not meet requirementSodium valproate 500 mg (#20#100) Does not meet requirement	Within DateSodium valproate 500 mg (#20#100) Within Date	Expired StockSodium valproate 500 mg (#20#100) Expired Stock	Supply IssueSodium valproate 500 mg (#20#100) Supply Issue
Thiamine 100mg (#50#100)	Meets requirementThiamine 100mg (#50#100) Meets requirement	Does not meet requirementThiamine 100mg (#50#100) Does not meet requirement	Within DateThiamine 100mg (#50#100) Within Date	Expired StockThiamine 100mg (#50#100) Expired Stock	Supply IssueThiamine 100mg (#50#100) Supply Issue

Tamper Proof Bags *

In Use & Intact
In Use & Damaged
Not in Use

Review Summary

	Action required	No action required
Stock requires adjustment	Action requiredStock requires adjustment Action required	No action requiredStock requires adjustment No action required
Expired stock requires replacement	Action requiredExpired stock requires replacement Action required	No action requiredExpired stock requires replacement No action required
Coordinator informed	Action requiredCoordinator informed Action required	No action requiredCoordinator informed No action required

Medication Fridge Temperature *

Within range- nil action required
Outside of range- temperature reset

Temperature at time of review *

(degrees Celcius)

Further comments