# Pediatric Pharmacy Competency Assessment

| Document ID | FRM-004 |
|-------------|---------|
| Title | Pediatric Pharmacy Competency Assessment |
| Revision | 1.0 |
| Effective Date | [DATE] |

---

## Employee Information

| Field | Value |
|-------|-------|
| Employee Name | ________________________________ |
| Position | ☐ Pediatric Pharmacist ☐ Pharmacy Technician ☐ Pharmacy Resident ☐ Student |
| License/Registration # | ________________________________ |
| Hire Date | ________________________________ |
| Assessment Date | ________________________________ |
| Assessment Type | ☐ Initial ☐ Annual ☐ Triggered ☐ Return from leave |

## Assessor Information

| Field | Value |
|-------|-------|
| Assessor Name | ________________________________ |
| Title | ________________________________ |
| License # | ________________________________ |
| Date | ________________________________ |

---

## Part 1: Pediatric Dosing Calculations

**Instructions:** Complete all calculations. 100% accuracy required. Show all work.

### Scenario 1: Weight-Based Dosing

**Patient:** 3-year-old male, weight 14.2 kg

**Order:** Amoxicillin 40 mg/kg/day divided every 8 hours

**Questions:**
1. Calculate total daily dose: ____________ mg/day
2. Calculate individual dose: ____________ mg per dose
3. Is this dose within the recommended range for amoxicillin (20-90 mg/kg/day)? ☐ Yes ☐ No

**Work shown:**
_____________________________________________________________________
_____________________________________________________________________

### Scenario 2: Maximum Dose Application

**Patient:** 12-year-old female, weight 52 kg

**Order:** Ondansetron 0.15 mg/kg IV for nausea

**Questions:**
1. Calculate dose based on weight: ____________ mg
2. Maximum dose for ondansetron is 16 mg. What dose would you dispense? ____________ mg
3. Why? _____________________________________________________________

**Work shown:**
_____________________________________________________________________
_____________________________________________________________________

### Scenario 3: BSA-Based Dosing

**Patient:** 7-year-old male, weight 25 kg, height 120 cm, BSA 0.92 m²

**Order:** Vincristine 1.5 mg/m² IV (chemotherapy)

**Questions:**
1. Calculate dose: ____________ mg
2. This dose will be independently verified by a second pharmacist because:
   ☐ High-alert medication
   ☐ Chemotherapy
   ☐ Both
   ☐ Neither

**Work shown:**
_____________________________________________________________________
_____________________________________________________________________

### Scenario 4: Neonatal Dosing

**Patient:** Premature infant, gestational age 32 weeks, postnatal age 5 days, weight 1.8 kg

**Order:** Gentamicin 4 mg/kg/dose IV every 24 hours

**Questions:**
1. Calculate dose: ____________ mg
2. For a 10 mg/mL concentration, what volume is needed? ____________ mL
3. Does the extended interval (q24h) make sense for this patient? ☐ Yes ☐ No
   Why? ____________________________________________________________

**Work shown:**
_____________________________________________________________________
_____________________________________________________________________

### Scenario 5: Dilution Calculation

**Patient:** 6-month-old infant, weight 7.5 kg

**Order:** Digoxin 10 mcg/kg/day divided BID

**Available:** Digoxin elixir 50 mcg/mL

**Questions:**
1. Total daily dose: ____________ mcg/day
2. Individual dose: ____________ mcg per dose
3. Volume to administer per dose: ____________ mL

**Work shown:**
_____________________________________________________________________
_____________________________________________________________________

---

## Part 2: Knowledge Assessment

**Instructions:** Answer all questions.

### 1. Pediatric Age Categories
Match the age to the correct category:

| Age | Category |
|-----|----------|
| 2 months | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
| 15 days | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
| 5 years | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
| 16 years | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |

### 2. High-Alert Medications
List 5 high-alert medications in pediatrics that require independent double-check:

1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
5. _________________________________

### 3. Weight Currency
What is the maximum age of weight for the following patient types?

- NICU/critical care inpatients: ☐ 24 hours ☐ 72 hours ☐ 1 week
- General inpatients: ☐ 24 hours ☐ 72 hours ☐ 1 week
- Outpatient infants (<1 year): ☐ 1 month ☐ 3 months ☐ 6 months

### 4. USP Standards
Which USP chapter covers non-sterile compounding?
☐ USP <795>
☐ USP <797>
☐ USP <800>

Which USP chapter covers sterile compounding?
☐ USP <795>
☐ USP <797>
☐ USP <800>

### 5. Off-Label Use
Approximately what percentage of medications used in pediatrics are off-label?
☐ <10%
☐ 25-30%
☐ 50-70%
☐ >90%

---

## Part 3: Practical Skills Assessment

**Instructions:** Assessor observes and evaluates performance.

### Skill 1: Order Verification and Dosing

**Task:** Process a pediatric medication order from start to finish

| Step | Satisfactory | Needs Improvement | Not Observed |
|------|--------------|-------------------|--------------|
| Verifies patient identity (name, DOB, MRN) | ☐ | ☐ | ☐ |
| Obtains current patient weight | ☐ | ☐ | ☐ |
| Verifies weight is current per policy | ☐ | ☐ | ☐ |
| Calculates dose accurately | ☐ | ☐ | ☐ |
| Checks dose against reference range | ☐ | ☐ | ☐ |
| Verifies maximum dose not exceeded | ☐ | ☐ | ☐ |
| Documents calculation appropriately | ☐ | ☐ | ☐ |
| Obtains independent verification if required | ☐ | ☐ | ☐ |
| Selects age-appropriate formulation | ☐ | ☐ | ☐ |

**Overall Performance:** ☐ Competent ☐ Needs additional training

**Comments:** ___________________________________________________________

### Skill 2: Compounding Oral Suspension (if applicable)

**Task:** Compound an oral suspension from tablets following SOP

| Step | Satisfactory | Needs Improvement | Not Observed |
|------|--------------|-------------------|--------------|
| Performs calculations correctly | ☐ | ☐ | ☐ |
| Prepares workspace appropriately | ☐ | ☐ | ☐ |
| Uses proper hand hygiene and garbing | ☐ | ☐ | ☐ |
| Crushes tablets to fine powder | ☐ | ☐ | ☐ |
| Uses geometric dilution correctly | ☐ | ☐ | ☐ |
| Achieves smooth, uniform suspension | ☐ | ☐ | ☐ |
| Brings to accurate final volume | ☐ | ☐ | ☐ |
| Labels correctly with all required info | ☐ | ☐ | ☐ |
| Assigns appropriate BUD | ☐ | ☐ | ☐ |
| Documents in compounding log | ☐ | ☐ | ☐ |

**Overall Performance:** ☐ Competent ☐ Needs additional training

**Comments:** ___________________________________________________________

### Skill 3: Patient/Family Counseling

**Task:** Counsel parent/guardian on pediatric medication

| Step | Satisfactory | Needs Improvement | Not Observed |
|------|--------------|-------------------|--------------|
| Introduces self and confirms patient | ☐ | ☐ | ☐ |
| Uses age-appropriate language | ☐ | ☐ | ☐ |
| Explains indication for medication | ☐ | ☐ | ☐ |
| Demonstrates dose measurement | ☐ | ☐ | ☐ |
| Emphasizes importance of accurate dosing | ☐ | ☐ | ☐ |
| Explains administration technique | ☐ | ☐ | ☐ |
| Reviews storage requirements | ☐ | ☐ | ☐ |
| Discusses common side effects | ☐ | ☐ | ☐ |
| Emphasizes completing full course | ☐ | ☐ | ☐ |
| Provides opportunity for questions | ☐ | ☐ | ☐ |

**Overall Performance:** ☐ Competent ☐ Needs additional training

**Comments:** ___________________________________________________________

---

## Part 4: Scenario-Based Assessment

### Scenario: Potential Error Identification

**Situation:** A 2-month-old infant (4.5 kg) has an order for gentamicin 15 mg IV every 8 hours.

**Usual neonatal dosing:** 4-5 mg/kg/dose every 24-48 hours (extended interval)

**Questions:**

1. Do you see any concerns with this order? ☐ Yes ☐ No

2. If yes, what are they?
   _________________________________________________________________
   _________________________________________________________________

3. What action would you take?
   ☐ Dispense as ordered
   ☐ Contact prescriber for clarification
   ☐ Refuse to fill
   ☐ Other: __________

4. Calculate what the dose should likely be:
   _________________________________________________________________

**Assessor evaluation:**
☐ Correctly identified potential error
☐ Appropriate action plan
☐ Accurate alternative dose calculation

---

## Assessment Results

### Part 1: Dosing Calculations
- Scenarios correct: ______ / 5
- **Required: 5/5 (100%)**
- Result: ☐ **PASS** ☐ **FAIL**

### Part 2: Knowledge Assessment
- Questions correct: ______ / 9
- **Required: 7/9 (78%)**
- Result: ☐ **PASS** ☐ **FAIL**

### Part 3: Practical Skills
- Skills demonstrated competently: ______ / 3
- **Required: 3/3**
- Result: ☐ **PASS** ☐ **FAIL**

### Part 4: Scenario Assessment
- Result: ☐ **PASS** ☐ **FAIL**

---

## Overall Assessment Result

☐ **COMPETENT** - All sections passed, authorized for independent practice

☐ **NEEDS REMEDIATION** - See below for areas needing improvement

☐ **NOT COMPETENT** - Requires additional training before reassessment

### Areas Needing Improvement:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

### Remediation Plan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

**Reassessment Date:** ____________________

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## Signatures

### Employee
I have completed this competency assessment to the best of my ability.

**Signature:** _________________________ **Date:** __________

### Assessor
I have assessed this employee's competency in pediatric pharmacy practice.

**Signature:** _________________________ **Date:** __________

**Printed Name:** _________________________ **License #:** __________

### Pharmacy Manager (if remediation required)
**Signature:** _________________________ **Date:** __________

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**Record Retention:** Maintained in employee file per regulatory requirements

**Next Assessment Due:** ____________________

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*Form FRM-004 Rev 1.0 - Pediatric Pharmacy*