OAR 855-041-5140
Technician Checking Validation Program (TCVP) - Initial Validation Process and Quality Assurance Process
(1)
Initial Validation Process: The initial process to validate a trainee’s ability to accurately check another technician’s work must include:(a)
Unit of Use: For initial validation of a trainee to check a unit of use cart fill, the trainee must obtain a 99.8% accuracy rate in 1500 total doses, divided among five separate training checks. A trainee who makes more than three errors in 1500 doses fails the validation and may not work as a technician checker until the checking process is repeated and until successfully completed.(A)
In each initial validation check, a pharmacist must check the accuracy of all unit of use medications after the trainee has checked them. The pharmacist must document any errors in the unit of use cart and discuss them with the trainee.(B)
In each initial validation check, the pharmacist will introduce at least three errors. The pharmacist coordinating the training check will keep a record of the introduced errors and will ensure that all introduced errors are removed before medications are distributed.(C)
The pharmacist must document the results of each initial validation check and retain the results in the quality assurance file.(b)
ADC or non-emergent trays and kits: For initial validation of a trainee to fill ADC or non-emergent trays and kits, the trainee must obtain a 99.8% accuracy rate in 500 total line items, divided among five separate training checks. A trainee who makes more than one error in 500 line items fails the validation and may not work as a technician checker until the checking process is repeated and until successfully completed.(A)
In each initial validation check, a pharmacist must check the accuracy of all ADC or non-emergent tray or kit medications after the trainee has checked them. The pharmacist must document any errors and discuss them with the trainee.(B)
In each initial validation check, the pharmacist will artificially introduce at least three errors. The pharmacist will keep a record of the introduced errors and will ensure that all introduced errors are removed before medications are distributed.(C)
The pharmacist must document the results of each initial validation check and retain the results in the quality assurance file.(2)
Quality Assurance Process: The Quality Assurance Process that ensures on-going competency of technician checkers must include:(a)
Quality checks conducted in the same manner as the applicable initial validation process described in section one of this rule, except that the quality check sample must consist of at least 300 doses for technicians checking unit of use carts and at least 100 line items for technicians checking ADC or non-emergent trays and kits.(b)
The quality checks must occur on random and unannounced dates and times.(c)
A technician checker who makes more than one error fails the quality check and may not work as a technician checker unless the technician first passes a second quality check within 30 days of the failed quality check. If the technician does not pass the second quality check within 30 days, the technician must be retrained and revalidated before working as a technician checker.(d)
The results of each quality check must be documented, including the total number of doses or line items checked, a description of each error, the total number of errors, and the percent error rate. Documentation must be retained in the quality assurance file.(3)
Timing and Frequency of Quality Checks: A technician checker must undergo a quality check at least monthly. A technician checker who has successfully completed three consecutive monthly quality checks must be checked at least quarterly for at least one year. A technician checker who has successfully completed four consecutive quarterly quality checks must be checked at least every six months.(4)
A technician checker who does not perform TCVP duties for more than six months must undergo initial validation as described in section one of this rule.(5)
A description of the quality assurance process must be included in the hospital’s and the pharmacy’s quality assurance program and error reporting system.
Source:
Rule 855-041-5140 — Technician Checking Validation Program (TCVP) - Initial Validation Process and Quality Assurance Process, https://secure.sos.state.or.us/oard/view.action?ruleNumber=855-041-5140.