AUS Medication Annual Risk Assessment

• Site conducted

  Select

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• • This audit tool complements the medication management audit that is conducted monthly at each site
  • Each Practice needs to determine those audit questions that are applicable to their facility circumstances for review.
  • The audit tool details each question and the action/criteria it aligns to in the standard
  • This audit tool has been adapted from the NSQHS Standard 4 Medication Safety Facility Audit tool Queensland Health to suite GenesisCare facilities
  
  

Facility Questions

• 1) Is there evidence that the Practice (e.g. Victoria) has a committee that oversees medication safety eg S& Q committee (note committee in comment section) If yes is there evidence that the committee;

  Yes

  No

  N/A

• 1.1 Has operational plans detailing the implementation and maintenance of facility medication safety systems?

  Yes

  No

  N/A

• 1.2 Has quality improvement plans that outline designated responsibilities and timeframes for completion of actions?

  Yes

  No

  N/A

• 1.3 Has mechanism for dissemination of medication safety alerts?

  Yes

  No

  N/A

• 1.4 Has minutes/ reports that include medication incident reports?

  Yes

  No

  N/A

• 1.5 Has performance measures for medication safety?

  Yes

  No

  N/A

• 1.6 Regularly reviews the storage, prescribing dispensing and administration of high-risk medicines?

  Yes

  No

  N/A

• 2) Does RiskMan reporting include medication incidents?

  Yes

  No

  N/A

• 2.1 Is there evidence that the facility records and acts on breaches of medication security?

  Yes

  No

  N/A

• 3) Is there evidence that the Practice provides staff education on medication safety system including;

  Yes

  No

  N/A

• 3.1 100% attendance at orientation and ongoing training for the clinical workforce relating to scope of practice?

  Yes

  No

  N/A

• 3.2 Training is matched to staff needs?

  Yes

  No

  N/A

• 3.3 Staff feedback reports on the sessions are evaluated and incorporated into next revisions?

  Yes

  No

  N/A

• 4) Is there evidence that the Practice has policies, procedures /guidelines and evaluation audits relating to safe management and quality use of medicines; Do they include?

  Yes

  No

  N/A

• 4.1 Safety distribution and storage of medicines?

  Yes

  No

  N/A

• 4.2 Monitoring temperatures in fridges used to store medicines?

  Yes

  No

  N/A

• 4.3 The disposal of unused, unwanted or expired medications?

  Yes

  No

  N/A

• 4.4 Use of the NIMC chart where applicable?

  Yes

  No

  N/A

• 4.5 Management of high risk medicines, including a list of high risk medicines relevant to the facility?

  Yes

  No

  N/A

• 4.6 Labelling injectable medicines, fluids and lines?

  Yes

  No

  N/A

• 4.7 Use of approved abbreviations for prescribing and administering

  Yes

  No

  N/A

• 4.8 Use of oral dispensers for administering liquid oral medicines?

  Yes

  No

  N/A

• 4.9 Specific procedures to ensure continuity of medicine management?

  Yes

  No

  N/A

• 4.10 Documentation of medication allergies and alerts?

  Yes

  No

  N/A

• 4.11 Documenting medication history on commencement of treatment and at end of treatment?

  Yes

  No

  N/A

• 4.12 Policies and procedures are accessible to the clinical workforce at the point of care and for managers?

  Yes

  No

  N/A

• 4.13 The process for implementation and distribution?

  Yes

  No

  N/A

• 4.14 Policies and procedures are current and regularly reviewed?

  Yes

  No

  N/A

Scope of practice

• 5.1 A system is in place to ensure individual workforce have authority to prescribe medicines and have professional registration/endorsements that are current?

  Yes

  No

  N/A

• 5.2 Position descriptions, duty statements and employment contracts detailing responsibilities, accountabilities and scope of practice for medication management ?

  Yes

  No

  N/A

• 6) Where Pharmacy provide services, are there regular reports by Pharmacy on system, usage and prescribing?

  Yes

  No

  N/A

• 7) Is there evidence that the facility provides a list and explanation of changes for patients on transfer or discharge?

  Yes

  No

  N/A

• 8) Is there evidence that the facility has a clinical handover program in place which includes tools to ensure the list of medicines if provided to the receiving clinician during handover

  Yes

  No

  N/A

• 9) Is there evidence that the facility regularly monitors the discharge summaries contain medicine information. Detail the actions taken to improve

  Yes

  No

  N/A

Consumer Feedback on information

• 10) Information such as consumer medicines information is available for patients?

  Yes

  No

  N/A

• 11) Information regarding medication treatment options, benefits and associated risks is available?

  Yes

  No

  N/A

• 12 ) Information where the workforce is aware of the information and can access it?

  Yes

  No

  N/A

• 13) Information where the needs of culturally and linguistically diverse patients are met?

  Yes

  No

  N/A

• 14) Is there evidence that the facility uses consumer complaints and compliments to improve provision of medicines information.? Detail improvements;

  Yes

  No

  N/A