Audit Tool for Medication Management in Approved Centres
Unit Name: ______
Objective of Audit tool:
This audit tool is to be used to retrospectively audit the processes used for medication management in Approved Mental Health Centres
Methodology:
Inclusion Criteria: All patients withinthe HSE Approved Mental Health Centres
Frequency of Audit: To be agreed by the MDT e.g.Every three months: Random selection of charts. The number of charts to be audited to be determined by each site based on bed numbers and assurance requirements – but no less than five charts to be audited every three months.
Method:This is a retrospective Medication audit
Feedback: Completed Audit Tool to be kept in the Audit File on the Unit.
Final page of the Audit Tool to be forward to the Director of Nursing/ Consultant for information and onward reporting.(this is example only - to be agreed by the MDT)
Ward / Date of AuditAuditor(s) Name(s) / Auditor(s) Title (s)
Patient Identifier (name/ number) / 1. / 2. / 3.
4. / 5. / 6.
Methodology: RecordY for Yes, if the item is found in the patient’s care record. Record N for No, the item is not present or N/Afor Not applicable
Audit Tool for Medication Management in Approved Centres
Unit Name: ______
Section A: Prior to the administration of medication
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6A1 / The patient’s full name is documented on the Prescription Sheet.
A2 / The patient’s date of birth is documented on the Prescription Sheet
A3 / The patient’s full address is documented on the Prescription Sheet
A4 / The patient’s identification number/ chart number is documented on the Prescription Sheet
A5 / The name of the relevant consultant is documented on the Prescription Sheet
A6 / The date of the prescriptive episode is documented on the Prescription Sheet
A7 / The relevant ward is documented on the Prescription Sheet
Prescriber Details
A8 / The prescription is signed by the Prescriber
A9 / The name of Prescriber is stated on the prescription in block capitals
A10 / The Medical Council Reg. Number of the Prescriber is stated on the prescription.
Prescription Details
A11 / The prescription is written the correct Prescription Sheet
A12 / The prescription is legible
A13 / The prescription is in black/indelible ink
A14 / Allergies or No Known Drug Allergy are documented as appropriate on the relevant section of the Prescription Sheet
A15 / The generic name of the medicinal product is used where relevant
A16 / The Start Date for the medication is documented
A17 / The strength/dosage is clearly documented on the Prescription Sheet
A18 / The route of administration is documented on the Prescription Sheet
A19 / The frequency of administration is documented on the Prescription Sheet
A20 / The maximum dose allowed in a 24 hour period is documented?
A21 / For Once Only/ PRN/Fixed Period Medications the duration of therapy is documented on the Prescription Sheet.
A22 / For Once Only/ PRN/Fixed Period Medications indications for the drug are documented
A23 / There is a documented date included for discontinuation of the medication or in the case of long term medication, a review date is indicated
A24 / Abbreviations are used in accordance with NHO/HSE Code of Practice for Records Management
A25 / A line has been drawn across the unused space on the prescription pad to prevent the fraudulent addition of extra items
Repeat Prescribing
A26 / There is evidence of an appropriate assessment of the need for continued treatment with the prescribed medication
A27 / In the event of the Prescriber being involved in a cross-over of responsibilities e.g. prescribing/supplying/dispensing/administering a medication, there is evidence that a second suitably competent person has been involved in checking the prescription
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
Total = 27(Total – N/A)
Comment:______
______
______
Section B: Administration of medication
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6B1 / The 5 rights of medication were applied for the patient?1. Right Service User
B2 / 2. Right Amount
B3 / 3. Right Time
B4 / 4. Right Drug
B5 / 5. Right Route
B6 / The practitioner administering the medication provided an accurate and contemporaneous recording of the medications administered, deliberately withheld, declined and/ or wasted
B7 / Any difficulties in the administration were documented and the medical practitioner was informed
B8 / If MDA Schedule 2 Drugs:
- The drugs were administered by two persons, at least one of which is a registered nurse
B9 /
- The control drug register was signed by two persons, at least one of which is a registered nurse
B10 / MDA Count is carried out at the end of each shift (at shift changeover) by two registered nurses
B11 / Any errors/ non-correlation in the MDA count are reported to nursing admin/ pharmacy
B12 / If patient brought in own MDA drugs to the unit, the type and amount were checked by two registered nurses and the MDA drugs are registered in the relevant section of the MDA book
B13 / If patient is discharged, the MDA drugs were returned to the patient and signed out of the MDA registerby two persons, at least one of which is a registered nurse
B14 / If MDA drugs will not be returned to the patient the drugs were returned in a secure manner to the pharmacy
B15 / If a medication error occurred: 15. The medical practitioner, responsible for the patient’s care, was informed?
B16 / 16. The patient’s next of kin were informed about the reaction?
B17 / 17. The Line Manager was informed?
B18 / 18. The patient was reviewed?
B19 / 19. The patient’s condition was monitored and vital signs recorded?
B20 / 20. All actions taken were documented?
B21 / 21. An ‘Incident/Near Miss Report Form’ was completed
B22 / If an adverse reaction occurred: 22. The medical practitioner, responsible for the patient’s care, was informed?
B23 / 23 The patient’s relative / key worker were informed about the reaction?
B24 / 24. The Line Manager was informed?
B25 / 25. The patient was reviewed?
B26 / 26. The patient’s condition was monitored and vital signs recorded?
B27 / 27. All actions taken were documented?
B28 / 28. An ‘Incident/Near Miss Report Form’ was completed?
B29 / 29 A Desk-top review/ follow up is documented
B30 / 30 The adverse reaction was reported to the IMB
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
Total = 30(Total – N/A)
Comment:__________
Section C: Medication Management - Audit Outcomes
Unit Name: ______Date: ______
Audit Results / 1 / 2 / 3 / 4 / 5 / 6% Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance
Section A
Section B
Audit Outcomes / 1 / 2 / 3 / 4 / 5 / 6
Yes / No / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
Care Plan processes were appropriately applied at all times
There were deviations from the correct Care Plan processes
Recommendations for improvement are required
Recommendations arising from the audit: / Date for completion / Responsibility
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5
Resident 6
Auditor Signature: ______Date:______
CNM Signature:______Date:______
Director of Nursing Signature: ______Date: ______
Audit Tool for Medication Management in Approved Centres, QPS DML, July 2014, Page 1 of 6