pediatric-pharmacy/Forms/Training/FRM-004-Pediatric-Pharmacy-Competency-Assessment.md

Pediatric Pharmacy Competency Assessment

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

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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	________________________________

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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:

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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:

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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:

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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:

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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:

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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%

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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: ___________________________________________________________

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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?

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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:

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

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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

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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:

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Remediation Plan:

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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