Checklist template

Immunization services for pharmacies

A ready-to-use checklist with 112 items in 6 sections, covering Storage, Consent and screening, Administration, Documentation, Emergency supplies, Area cleanliness. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 112 Items
  • 95 Yes / No checks
  • 6 Scored ratings
  • 125 Points

Use this template How audits work

1. Storage 23 items

  1. Vaccine refrigerator temperature at the time of the visit (°F or °C) Number
  2. The vaccine refrigerator reads between 36°F and 46°F (2°C and 8°C) Yes / No 1 pt
  3. Vaccine freezer temperature at the time of the visit, where frozen vaccines are stocked (°F or °C) Number
  4. The vaccine freezer reads between -58°F and 5°F (-50°C and -15°C) Yes / No 1 pt
  5. Today's minimum and maximum temperatures were recorded before the first dose of the day was given Yes / No 1 pt
  6. The vaccinator reads the temperature display each time a dose is taken from the unit Yes / No 1 pt
  7. The door of the unit is closed as soon as the dose is taken out, not left open while the dose is prepared Yes / No 1 pt
  8. Only the doses for the patient in the room are taken out of the unit Yes / No 1 pt
  9. The vaccine storage unit is inside the dispensary or the locked immunization room, out of reach of the public Yes / No 1 pt
  10. No expired vaccine is in the refrigerator or freezer Yes / No 1 pt
  11. Last season's influenza vaccine has been removed from the unit Yes / No 1 pt
  12. The dose with the earliest expiry date is the one taken first Yes / No 1 pt
  13. Vaccine expiring within the next 30 days carries a short-date sticker Yes / No 1 pt
  14. Each vaccine on the pharmacy's list of services is in stock Yes / No 1 pt
  15. Doses on hand cover the appointments booked for the next 7 days Yes / No 1 pt
  16. Influenza vaccine doses on hand, in season Number
  17. The influenza vaccine recommended for older adults is in stock, in season Yes / No 1 pt
  18. Vaccine ordered for a named patient (travel vaccines, series doses) is tagged with the patient's name Yes / No 1 pt
  19. The next dose of a series is reserved or reordered when a dose is given Yes / No 1 pt
  20. Pediatric and adult presentations of the same vaccine are in separate, labeled bins Yes / No 1 pt
  21. Opened multi-dose vials are kept in a marked bin at the front of the shelf Yes / No 1 pt
  22. An employee asked could state where vaccines go during a power failure Yes / No 1 pt
  23. Vaccine storage for the service Rating
    • In range, in date and stocked for the appointments booked 5 pts
    • In range and in date, with a vaccine missing or short for booked appointments 3 pts
    • Out of range or expired vaccine in the unit 1 pt

2. Consent and screening 17 items

  1. A screening questionnaire was completed before vaccination in each of 5 patient records sampled Yes / No 1 pt
  2. The questionnaire asks about allergies, reactions to earlier vaccines, pregnancy, weakened immunity and current illness Yes / No 1 pt
  3. The pharmacist signs or initials the screening before the dose is prepared Yes / No 1 pt
  4. Consent is signed by the patient, or by a parent or guardian for a minor Yes / No 1 pt
  5. Patients below the minimum age set by local regulation for pharmacy vaccination are referred elsewhere Yes / No 1 pt
  6. A current standing order, protocol or prescription is on file for each vaccine offered Yes / No 1 pt
  7. Review or expiry date of the vaccination protocol on file Date
  8. The current edition of the vaccine information sheet is given to the patient before the injection Yes / No 1 pt
  9. The immunization registry or the patient's history is checked for earlier doses before a vaccine is given Yes / No 1 pt
  10. The interval since the previous dose is checked against the schedule for multi-dose series Yes / No 1 pt
  11. Insurance or public program eligibility is confirmed before the dose is prepared Yes / No 1 pt
  12. Patients are asked whether they have fainted after an injection before Yes / No 1 pt
  13. Patients are told before the injection that they will be asked to stay for 15 minutes Yes / No 1 pt
  14. Walk-in patients are quoted a waiting time Yes / No 1 pt
  15. Screening questionnaires are available in the main languages of the store's patients Yes / No 1 pt
  16. Patient records sampled with screening and consent complete (out of 5) Number
  17. Screening and consent in the records sampled Rating
    • Complete in all 5 5 pts
    • 1 record incomplete 3 pts
    • 2 or more incomplete 1 pt

3. Administration 20 items

  1. Every employee who vaccinates has a current immunization training certificate on file at the pharmacy Yes / No 1 pt
  2. Every employee who vaccinates has a current CPR or basic life support certificate on file Yes / No 1 pt
  3. The vaccinator cleans their hands before each patient Yes / No 1 pt
  4. The patient's name and date of birth are confirmed in the room before the dose is prepared Yes / No 1 pt
  5. The vaccine name is read against the order before the dose is drawn up Yes / No 1 pt
  6. The expiry date on the vial or syringe is checked before the dose is drawn up Yes / No 1 pt
  7. Doses are drawn up at the time of administration; no pre-drawn syringes are stored Yes / No 1 pt
  8. Multi-dose vials are labeled with the date and time of first puncture Yes / No 1 pt
  9. Multi-dose vials past the manufacturer's time limit after first puncture are discarded Yes / No 1 pt
  10. The vial stopper is wiped with an alcohol swab before each puncture Yes / No 1 pt
  11. A chart of injection sites and needle lengths by age is posted in the room Yes / No 1 pt
  12. Needle lengths for children, adults and larger adults are all in stock Yes / No 1 pt
  13. The injection site is cleaned and left to dry before the injection Yes / No 1 pt
  14. Needles with a safety shield are used Yes / No 1 pt
  15. Used needles go into the sharps container without being recapped Yes / No 1 pt
  16. The patient is seated for the injection Yes / No 1 pt
  17. Patients waiting 15 minutes after the injection sit within sight of pharmacy staff Yes / No 1 pt
  18. Vaccines requiring reconstitution are mixed only with the diluent supplied by the manufacturer Yes / No 1 pt
  19. Vaccinations observed during the visit Number
  20. Injection practice observed Rating
    • Every step followed 5 pts
    • Minor lapses not affecting safety 3 pts
    • Checks or hygiene steps skipped 1 pt

4. Documentation 17 items

  1. Each of 5 records sampled shows the vaccine, lot number, expiry date, dose, site, route, date and vaccinator Yes / No 1 pt
  2. Lot numbers in the records sampled match lots received by the pharmacy Yes / No 1 pt
  3. Doses are reported to the immunization registry within the time required by local regulation Yes / No 1 pt
  4. The patient's primary care provider is notified where local regulation or the protocol requires it Yes / No 1 pt
  5. Each patient receives a written or electronic record of the vaccine given Yes / No 1 pt
  6. Signed consent forms sampled were retrieved within 5 minutes Yes / No 1 pt
  7. Vaccination records are kept for the period required by local regulation Yes / No 1 pt
  8. Adverse reactions are documented in the patient's record Yes / No 1 pt
  9. Adverse reactions are reported to the public health reporting system as local regulation requires Yes / No 1 pt
  10. Administration errors (wrong vaccine, wrong interval, expired dose) are entered in the incident system Yes / No 1 pt
  11. The claim billed matches the vaccine recorded in the records sampled Yes / No 1 pt
  12. Wasted or spoiled doses are logged with the reason Yes / No 1 pt
  13. Doses received, given, wasted and on hand are reconciled at least once a month Yes / No 1 pt
  14. Publicly funded vaccine is stored and counted separately from privately purchased stock Yes / No 1 pt
  15. Doses administered last month Number
  16. Doses wasted or spoiled last month Number
  17. Completeness of vaccination records sampled Rating
    • All complete and reported 5 pts
    • Minor omissions 3 pts
    • Lot numbers, consent or registry reports missing 1 pt

5. Emergency supplies 17 items

  1. An anaphylaxis kit is kept in the immunization room, within reach of the vaccinator Yes / No 1 pt
  2. The kit holds at least two doses of epinephrine in the adult strength Yes / No 1 pt
  3. The kit holds at least two doses of epinephrine in the pediatric strength, where children are vaccinated Yes / No 1 pt
  4. No item in the anaphylaxis kit is expired Yes / No 1 pt
  5. Earliest expiry date of the epinephrine in the kit Date
  6. The kit contains the antihistamine named in the emergency protocol Yes / No 1 pt
  7. A CPR barrier mask is in or beside the kit Yes / No 1 pt
  8. A blood pressure monitor with adult and child cuffs is available in the room Yes / No 1 pt
  9. The emergency protocol with epinephrine doses by age or weight is posted in the room Yes / No 1 pt
  10. The kit is checked monthly and the check is initialed Yes / No 1 pt
  11. An employee asked could state the first three steps for a suspected anaphylactic reaction Yes / No 1 pt
  12. A phone is in or beside the room for calling emergency services Yes / No 1 pt
  13. The store's street address is posted beside that phone Yes / No 1 pt
  14. There is floor space in or beside the room to lay a patient flat Yes / No 1 pt
  15. The needlestick injury procedure is posted in the room Yes / No 1 pt
  16. The emergency protocol was reviewed or practiced with vaccinators in the last 12 months Yes / No 1 pt
  17. Readiness for an adverse reaction Rating
    • Kit complete, in date, staff know the steps 5 pts
    • Kit complete but staff unsure 3 pts
    • Kit incomplete or expired 1 pt

6. Area cleanliness 18 items

  1. The immunization room or screened area is used only for patient care, not for storing stock Yes / No 1 pt
  2. A door or screen closes so that the patient cannot be seen during the injection Yes / No 1 pt
  3. The patient chair has armrests and a wipeable surface without tears Yes / No 1 pt
  4. The chair and the work surface are wiped with disinfectant between patients Yes / No 1 pt
  5. Disinfectant wipes in the room are within their expiry date Yes / No 1 pt
  6. Hand sanitizer or a sink with soap is within reach of the vaccinator Yes / No 1 pt
  7. The surface where doses are prepared is clear of paperwork and personal items Yes / No 1 pt
  8. The sharps container is mounted on the wall or placed out of the reach of children Yes / No 1 pt
  9. The sharps container is below its fill line Yes / No 1 pt
  10. Full sharps containers are sealed and kept in a locked area until collected Yes / No 1 pt
  11. The chairs used for the 15-minute wait are wiped with disinfectant at least once a day Yes / No 1 pt
  12. The trash container in the room is emptied daily Yes / No 1 pt
  13. The floor of the room is clean and free of used swabs, caps or bandages Yes / No 1 pt
  14. Bandages, swabs and syringes are stocked in closed drawers or cabinets Yes / No 1 pt
  15. Needles and syringes are locked away when the room is unattended Yes / No 1 pt
  16. Name of the pharmacist in charge Short text
  17. Overall immunization service Rating
    • Safe, well documented and ready for emergencies 5 pts
    • Safe, with gaps in records or supplies 3 pts
    • Unsafe practices or missing records 1 pt
  18. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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