Tool for audit of Medication Management in Residential Services for Older Persons
Residential Unit Name: ______
Objective of Audit tool:
This audit tool is to be used to retrospectively audit the processes used for Medication Management in HSE Residential Services for Older Persons
Methodology:
Inclusion Criteria: All persons residing within the HSE Residential Units for Older Persons in ______(Insert Location)
Frequency of Audit*: 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.
(*Note: this is just a suggestion – frequency to be determined by each individual service)
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 for information and onward reporting.
Ward / Date of AuditAuditor(s) Name(s) / Auditor(s) Title (s)
Resident Identifier (name/ medical card number) / 1. / 2. / 3.
4. / 5. / 6.
Methodology: Record Y for Yes, if the item is found in the resident’s care record.
Record N for No, the item is not present or N/A for Not applicable
Audit Tool for Medication Management in Residential Care Service
Residential Unit Name: ______
Section A: Prior to the administration of medication
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6A1 / Name of patient is written on each page of drug chart
A2 / Their prescription was written on a recognised chart and Allergy and ADR sections are filled in
A3 / The prescription is in indelible ink?
A4 / The drug order is clearly written, using the 24 hour clock and is dated and signed?
A5 / The generic name of the medication is prescribed?
A6 / The dose is clearly specified?
A7 / The route And frequency of administration was stated?
A8 / The prescription was signed and dated by a registered medical practitioner/registered nurse prescriber?
A9 / A new drug order that replaces an earlier drug order is re-prescribed?
A10 / A registered medical practitioner has cancelled the earlier drug order by signing and drawing a line through the order?
A11 / Information in relation to the medication was given to the resident and / or next of kin by the pharmacist at the 3/12 review this is documented in the patients pharmaceutical care plan which is kept on the ward?
A12 / In the event of PRN prescription, the medical practitioner has documented the maximum dose allowed in a 24 hour period?
A13
A14
A15 / If resident prescribed the following during the previous month, it was recorded on the HIQA Resident Monitoring Form? 13: Antimicrobial drugs
14: Flu Vaccination/Pneumococcal/Any other vaccination
15: Psychotropic drugs
A16 / If Antimicrobial/ short term drugs prescribed, there is a start date
A17 / If Antimicrobial prescribed, there is an review/end date
A18 / There is evidence of a three monthly review of medications by the GP/Pharmacist/Nurse as part of the multidisciplinary review
A19 / Where oxygen therapy is required is it appropriately prescribed in the patient chart
A20 / Where Warfarin therapy is required is it appropriately prescribed in the patient chart
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
20 – Total N/A
Comment: ______
______
______
Section B: Administration of medication Record Y for Yes, N for No or N/A for Not applicable
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6B1
B2
B3
B4
B5 / The 5 rights of medication were applied for the resident? 1. Right Service User
2. Right Amount
3. Right Time
4. Right Drug
5. Right Route
B6 / The registered nurse 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
B9 / If MDA Schedule 2 Drugs:
8. The drugs were administered by two persons, at least one of which is a registered nurse
9. 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 resident 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 resident and signed out of the MDA register by two persons, at least one of which is a registered nurse
B14 / If MDA drugs will not be returned to the resident the drugs were returned in a secure manner to the pharmacy via the locked blue medication box complete with the controlled drug requisition book detailing return of patients medication for destruction
B15
B16
B17
B18
B19 B20
B21
B22 / If a medication error occurred: 15. The medical practitioner, responsible for the resident’s care, was informed?
16. The resident’s next of kin were informed about the reaction?
17. The Line Manager was informed?
18. The pharmacist was informed?
19. The resident was reviewed?
20. The resident’s condition was monitored and vital signs recorded?
21. All actions taken were documented?
22. An ‘Incident/Near Miss Report Form’ was completed
B23
B24
B25
B26
B27
B28
B29
B30 B31
B32 / If an adverse reaction occurred: 23. The medical practitioner, responsible for the resident’s care, was informed?
24. The resident’s relative / key worker were informed about the reaction?
25. The Line Manager was informed?
26. The pharmacist was informed
27. The resident was reviewed?
28. The resident’s condition was monitored and vital signs recorded?
29. All actions taken were documented?
30. An ‘Incident/Near Miss Report Form’ was completed?
31. A Desk-top review/ follow up is documented
32. The adverse reaction was reported to the IMB
B33 / Where a variable dose is prescribed, is the administration amount recorded
B34 / Initials of the staff member administering the medication to the resident were recorded on the Drug Prescription and Administration Record?
B35 / Drugs requiring a witness - have the Initials of the witnessing registered nurse or GP been recorded on the Drug Prescription and Administration Record?
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
35 – Total N/A
Comment:__________
Section C: Audit Outcomes and Recommendations
Unit: ______Ward: ______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
Medication processes were appropriately applied at all times
There were deviations from the correct Medication 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 Residential Services for Older Persons, QPS DML, June 2014 Page 5 of 5