Title Page

  • Site conducted

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • 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;

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

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

  • 1.3 Has mechanism for dissemination of medication safety alerts?

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

  • 1.5 Has performance measures for medication safety?

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

  • 2) Does RiskMan reporting include medication incidents?

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

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

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

  • 3.2 Training is matched to staff needs?

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

  • 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?

  • 4.1 Safety distribution and storage of medicines?

  • 4.2 Monitoring temperatures in fridges used to store medicines?

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

  • 4.4 Use of the NIMC chart where applicable?

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

  • 4.6 Labelling injectable medicines, fluids and lines?

  • 4.7 Use of approved abbreviations for prescribing and administering

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

  • 4.9 Specific procedures to ensure continuity of medicine management?

  • 4.10 Documentation of medication allergies and alerts?

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

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

  • 4.13 The process for implementation and distribution?

  • 4.14 Policies and procedures are current and regularly reviewed?

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?

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

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

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

  • 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

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

Consumer Feedback on information

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

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

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

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

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.