1. Wendy Jordan, Pharm.D. Inpatient Pharmacy Manager St. Bernards Medical Center

2. St. Bernards Timeline Hospital Committee Approval of Policies & Procedures – March 2015 Selection and training of TCT Technicians – March 2015 to August 2015 Random Audits – September 2015 (1 Technician) Two batch runs were selected Total doses checked = 169 Accuracy Rate = 100%

3. TCT Education Five technicians identified as possible candidates per policy – Three technicians selected for training – Two technicians completed training One Technician did not complete training due to: » Staffing restraints » Change in positions of pharmacist trainers – Didactic Exam (N=3) Average score = 94% – There was no re-training required

4. Validated Doses with Artificial Errors

5. Total doses checked Total errors introduced Total errors discovered Percentage Found Tech A51910 100% Tech B58812 100% Introduced Errors

6. Introduced Error Types

7. Tech-Check-Tech Pilot Updates Jackie Acuña, Pharm D Clinical Pharmacist I Baptist Health North Little Rock

8. Timeline of Pilot Implementation Pilot approval of TCT by ABoP – February 2015 Selection and training of VPT – February 2015- April 2015 Policies and Procedures reviewed and approved by QRC – April 2015 TCT Pilot implemented in central pharmacy – May 4, 2015 TCT Random Audits – August 2015 – October 2015 (6 months of data) 8

9. Training Overview Technician selection- policy based Technician re-education – Didactic education Self-learning Important sections emphasized by TCTPC – Didactic exam (n=4) Average score 96% (+/- 3.26) 9

10. Re-education Four technicians qualified for training per policy – Two technicians completed training process – Two technicians required re-education Review and discuss training packet Additional 500 line items checked – One technician did not complete the validation process 10

11. Total Doses Checked 11

12. VPT Validation Process 12 Total doses checked Total Errors introduced Total Errors discovered Percentage found A58958 100% B51157 100% C101110910799.80%

13. Total Randomized Errors 13

14. Introduced Errors vs Errors Discovered 14

15. August Random Audit Student intern/APPE – Randomized nursing unit selection process Three nursing units verified per random day – Verified after the medications had been pulled for distribution – VPT blinded to the auditing process and dates audits were to be conducted No mistakes were found during this review 15

16. October Quality Assurance Audit Per policy- Audit will consist of at least 10 % of ADC batch runs – Each VPT checked an average of 232 doses (3 batch runs) Errors were introduced at a rate of 1% – The accuracy rate for each technician was 100% 16

17. Next Steps Present to ABoP final results of year-long pilot – March 2016 AAHP Hospital Advisory Committee – Currently drafting recommended regulations – Will be reviewed by the AAHP Board of Directors Review of proposed regulations by ABoP 17