Medication Management Audit Tips
Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents are (first two are key for residential care):
- Medication Care Guides for Residential Aged Care 2011 – MoH
- Standing Order Guidelines 2012 – MoH
- Medicines Act 1981 and Medicines Regulations 1984
- Misuse of Drugs Act 1975 and Regulations 1977
- Health Practitioners Competency Assurance Act 2003
Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments. Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished. Below are common errors which continue to be made:
| Aspect of medication management |
Common Errors |
| Medication charts |
Not dated Not signed by the prescriber Not signed by the General Practitioner or Nurse Practitioner at each review (3 monthly) Not legible Allergies not documented (or inconsistent with other resident documents) Transcribing on medication charts or PRN signing sheets PRN medication charting does not include ‘indication for use’ Medication order does not include time, dose, frequency, route, type etc |
| Signing sheets |
Missed signatures on the signing sheets Only one signature (instead of two) on controlled drug administration records and register PRN medication not signed for accurately |
| Self-medicating residents |
Competency to verify self-medication not signed by prescriber Competency for self-medication not signed as having been reviewed by prescriber (3 monthly) Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order) Not retaining a current list of all medication ordered for self-medicating residents |
| Storage |
Medication not securely stored (also see ARRC D15.3(c) Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy) Controlled drugs not stored in locked cabinet in locked room Drug trolley left in common areas unlocked Expired medication continue to be stored on site (should be returned to pharmacy) Medication for resident who has been discharge or deceased remain on site Medication fridge temperature not monitored / recorded Labels on medication containers not clear / legible |
| Identification of resident |
Photograph not representative of current presentation of resident (photograph should be colour) Photograph of residents not validated regularly |
| Medication errors |
Not reported Not managed (through an adverse event management process to ensure identification of contributing factor and preventive measures). |
| Competency |
All staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competency Annual review of medication competencies |
If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor. The risk is too high for the residents and your organisation. Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.
Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty. Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering. Refer to the Aged Related Residential Care Contract (ARRC) for further information.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.