HIGH-ALERT MEDICATION — INDEPENDENT DOUBLE-CHECK
Hospital: ________________________ | Dept Anesthesia	Form Code: F-24 | Version: ___ | Effective: ___ | PAGE 1 of 1

SECTION 1 — PATIENT / SETTING
Date/Time: ____________________________________ Location:   ☐ OR    ☐ NORA    ☐ PACU	Patient MRN: __________________________________ Case/Procedure: _______________________________

SECTION 2 — MEDICATION ORDER
Medication: ________________________________________________ Concentration: ________________________________________________ Route/Line: ☐ IV    ☐ Central    ☐ Arterial line flush ☐ Epidural (if applicable)    ☐ Other: ____________	Indication/Target: ________________________________________________ ________________________________________________ Allergies checked: ☐ Yes       ☐ No

SECTION 3 — PUMP / DELIVERY
Device: ☐ Smart pump    ☐ Syringe pump    ☐ Gravity Drug library used (if smart pump): ☐ Yes    ☐ No    ☐ N/A Rate: ______________    Units: ______________ Bolus (if any): ________________________________	Line traced from source to patient: ☐ Yes       ☐ No Labeling complete (syringe/bag + line): ☐ Yes       ☐ No

SECTION 4 — INDEPENDENT DOUBLE-CHECK SIGN-OFF
Checker #1 (preparer/administrator): Name/ID: _____________________________________ Signature: ______________________ Time: ________	Checker #2 (independent verifier): Name/ID: _____________________________________ Signature: ______________________ Time: ________

SECTION 5 — NOTES / VARIANCES

If any variance found, STOP and correct before start. Notes: _______________________________________________________________________________________________ ______________________________________________________________________________________________________