BDM Care Medication Audit Tool with Action Plan

Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

General Information

During this audit, one MARS record should be used as a sample during the audit process. If any errors are found, a further two records should be audited. If any further errors are found this will necessitate a full audit of all MARS

MARS records used for sampling during audits should be selected on a rotational basis.

Section 1

1 - Overview

1.1 Total number of available beds
1.2 Total number of beds occupied?
1.3 Has the previous audit been reviewed and signed off?
1.4 How many corrective actions were raised during the last audit?
1.5 Have all corrective actions raised during the last audit been completed? If not give further details.

Section 2

2 - Management of Medication

2.1 Is there an up to date list of all staff who administer drugs complete with sample signatures?
Action required
By who
Date for completion
Date completed
Sign
2.2 Is there a written procedure for the administration of drugs in use?
Action required
By who
Date for completion
Date completed
Sign
2.3 Have all staff who administer medication been trained and assessed as competent?
Action required
By who
Date for completion
Date completed
Sign
2.4 Is a copy of the BNF available and is this under twelve months old?
Action required
By who
Date for completion
Date completed
Sign
2.5 Is there a policy in place for: Obtaining, Receipt and Storage of medicines Handling and Administration of medicines Monitoring of medicines Disposal of medicines Handling and Review of incidents / errors / near misses Homely Remedies Covert medication Social Leave Self-administration of medication
Action required
By who
Date for completion
Date completed
Sign
2.6 Has a cosh assessment been completed for hazardous substances e.g. Cytotoxics, oxygen?
Action required
By who
Date for completion
Date completed
Sign
2.7 Further comments / observations for Management of Medication

Section 3

3 - Ordering of Medication

3.1 Do you have a specific named contact at the surgery and at the pharmacy where medication is ordered?
Action required
By who
Date for completion
Date completed
Sign
3.2 Are there designated members of the team who deal with the ordering of medication?
Action required
By who
Date for completion
Date completed
Sign
3.3 Are all requests for prescriptions auctioned in a timely manner?
Action required
By who
Date for completion
Date completed
Sign
3.4 Is there a procedure in place for obtaining emergency supplies of medicines? E.g out of hours, bank holidays.
Action required
By who
Date for completion
Date completed
Sign
3.5 Further comments / observations:

Section 4

4 - Medication and Administration

4.1 Is a monitored dosage system in place and if so is it operated satisfactorily in your home?
Action required
By who
Date for completion
Date completed
Sign
4.2 Are all medicines clearly labelled in accordance with requirements?
Action required
By who
Date for completion
Date completed
Sign
4.3 Are all medicines within their expiry date?
Action required
By who
Date for completion
Date completed
Sign
4.4 Does the strength of the medication correspond with that written on the treatment sheet?
Action required
By who
Date for completion
Date completed
Sign
4.5 Are all medicines appropriately signed for at the time of administration?
Action required
By who
Date for completion
Date completed
Sign
4.6 Do MAR sheets have a means of identifying the patient? E.g photograph and room number?
Action required
By who
Date for completion
Date completed
Sign
4.7 Does the MAR sheet tally with the amount of medicine in stock?
Action required
By who
Date for completion
Date completed
Sign
4.8 If prescription states take 1 or 2 tablets, does the treatment sheet identify clearly wether 1 or 2 are administered?
Action required
By who
Date for completion
Date completed
Sign
4.9 Do the instructions state 'as directed'? Are instructions clarified with GP before administration?
Action required
By who
Date for completion
Date completed
Sign
4.10 If medication is PRN does it state in what circumstances it is to be administered?
Action required
By who
Date for completion
Date completed
Sign
4.11 Is a record made of any doses omitted with a reason why? (I.e. appropriate coding used to acknowledge reason)
Action required
By who
Date for completion
Date completed
Sign
4.12 Are all external medications recorded when administered or applied?
Action required
By who
Date for completion
Date completed
Sign
4.13 Are eye drops and insulin dated when opened and discarded after one month?
Action required
By who
Date for completion
Date completed
Sign
4.14 Is there evidence of regular medication reviews?
Action required
By who
Date for completion
Date completed
Sign
4.15 Where additional knowledge is required for administration e.g. Insulin, PEG tubes, rectal products have staff been trained in these techniques including formal assessment of competency?
Action required
By who
Date for completion
Date completed
Sign
4.16 Further comments / observations:

Section 5

5 - Labelling of Medicines

5.1 Do all service users have their own individual supply?
Action required
By who
Date for completion
Date completed
Sign
5.2 Is each medication clearly labelled by a pharmacist or GP?
Action required
By who
Date for completion
Date completed
Sign
5.3 Are labels in original condition and not changed by hand?
Action required
By who
Date for completion
Date completed
Sign
5.4 Is the medication labelled, not just on the outer box (e.g. Labels on tubes and not just the box)?
Action required
By who
Date for completion
Date completed
Sign
5.5 Is a patient information leaflet available for each medicine store at the home?
Action required
By who
Date for completion
Date completed
Sign
5.6 Further comments / observations:

Section 6

6 - Storage of Medication

6.1 Is there a secure and designated storage area for medicines and medicine trolleys?
Action required
By who
Date for completion
Date completed
Sign
6.2 Are the keys for the medical cupboard and CD cupboard kept separate from other keys?
Action required
By who
Date for completion
Date completed
Sign
6.3 Is access to these keys and medical storage facilities restricted to authorised staff only?
Action required
By who
Date for completion
Date completed
Sign
6.4 Are external medications stored in a separate locked cupboard or on a separate shelf in the storage area?
Action required
By who
Date for completion
Date completed
Sign
6.5 Are all medicinal products, dressings and osteomyelitis products stored off the floor at all times?
Action required
By who
Date for completion
Date completed
Sign
6.6 When new medication arrives atnthenhome is there a stock rotation system in place?
Action required
By who
Date for completion
Date completed
Sign
6.7 Are stock levels of reserve drugs acceptable and appropriate for individual use?
Action required
By who
Date for completion
Date completed
Sign
6.8 Are discontinued / expired medicines removed from the trolley promptly?
Action required
By who
Date for completion
Date completed
Sign
6.9 Are medicines no longer required returned to pharmacy promptly?
Action required
By who
Date for completion
Date completed
Sign
6.10 Are all medicines returned to the pharmacy signed for by the accepting pharmacy?
Action required
By who
Date for completion
Date completed
Sign
6.11 Are all medicines stored in locked cupboards / trolleys? Is the trolley anchored to the wall?
Action required
By who
Date for completion
Date completed
Sign
6.12 Are there any medications requiring storage in a fridge and if so are they stored correctly?
Action required
By who
Date for completion
Date completed
Sign
6.13 Is there a maximum / minimum thermometer in the fridge?
Action required
By who
Date for completion
Date completed
Sign
6.14 Is the fridge regularly cleaned and defrosted?
Action required
By who
Date for completion
Date completed
Sign
6.15 Is the temperature of the fridge monitored and recorded on a daily basis?
Action required
By who
Date for completion
Date completed
Sign
6.16 Are staff aware of the procedure to follow if the fridge temperature is outside the 2-8 deg. Range?
Action required
By who
Date for completion
Date completed
Sign
6.17 Is storage satisfactory for oxygen cylinders and in accordance with the Health & Safety regulations?
Action required
By who
Date for completion
Date completed
Sign
6.18 Is a warning notice displayed at each location where oxygen is stored or in use?
Action required
By who
Date for completion
Date completed
Sign
6.19 Further comments / observations:

Section 7

7 - Controlled Drugs

7.1 Does the controlled drug cupboard comply with legislative requirements? E.g. Is it a locked cupboard within a locked cupboard?
Action required
By who
Date for completion
Date completed
Sign
7.2 Is a dedicated controlled drug register available?
Action required
By who
Date for completion
Date completed
Sign
7.3 Do stock levels held balance with the controlled drug register?
Action required
By who
Date for completion
Date completed
Sign
7.4 Are all controlled drug administrations witnessed and are two signatures obtained?
Action required
By who
Date for completion
Date completed
Sign
7.5 Care homes providing personal care: Are CD's administered and witnessed by a designated and appropriately trained member of staff?
Action required
By who
Date for completion
Date completed
Sign
7.6 Care homes providing nursing care: Are CD's administered by a registered medical,practitioner or registered nurse?
Action required
By who
Date for completion
Date completed
Sign
7.7 Is a separate page used for each person and each CD?
Action required
By who
Date for completion
Date completed
Sign
7.8 Further comments / observations:

Section 8

8 - Staff Training

8.1 Have all staff who handle medication received training in the safe handling of medicines?
Action required
By who
Date for completion
Date completed
Sign
8.2 Is all staff training documented?
Action required
By who
Date for completion
Date completed
Sign
8.3 Is training accredited and does it cover the skills for Care Knowledge Set for Medication?
Action required
By who
Date for completion
Date completed
Sign
8.4 Is there a refresher course for staff?
Action required
By who
Date for completion
Date completed
Sign
8.5 Is there a procedure in place to deal with all relevant medicine related patient safety communications issued via alert systems within the required timescales?
Action required
By who
Date for completion
Date completed
Sign
8.6 Is there a procedure in place to communicate relevant information within the administration team?
Action required
By who
Date for completion
Date completed
Sign
8.7 Is there a procedure in place for reporting incidents, errors and omissions?
Action required
By who
Date for completion
Date completed
Sign
7.8 Further comments / observations:

Audit Criteria

Audit Criteria and Additional Comments:

Number of records inspected during this audit.
Details of records inspected during this audit
How many corrective actions were raised from this audit?
Audit Completed By:
Review Date
Audit Reviewed By:

BDM Care Medication Audit Tool with Action Plan

Go digital today!

Convert your paper checklists into digital forms

1 - Overview

2 - Management of Medication

3 - Ordering of Medication

4 - Medication and Administration

5 - Labelling of Medicines

6 - Storage of Medication

7 - Controlled Drugs

8 - Staff Training

Audit Criteria and Additional Comments:

Related checklists

BDM Care Medication Audit Tool with Action Plan

Free BDM Care Medication Audit Tool with Action Plan Checklist

Go digital today!

Convert your paper checklists into digital forms

1 - Overview

2 - Management of Medication

3 - Ordering of Medication

4 - Medication and Administration

5 - Labelling of Medicines

6 - Storage of Medication

7 - Controlled Drugs

8 - Staff Training

Audit Criteria and Additional Comments:

Related checklists