Standard 4 - Audit Report

Criterion 1 - Governance and systems for medication safety

4.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organization wide medication safety systems

4.1.2 Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

4.2.1 The medication management system is regularly assessed

4.2.2 Action is taken to reduce the risks identified in the medication management system

4.3.1 A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

4.3.2 The use of the medication authorization system is regularly monitored

4.3.3 Action is taken to increase the effectiveness of the medication authority system

4.4.1 Medication incidents are regularly monitored, reported and investigated

4.4.2 Action is taken to reduce the risk of adverse medication incidents

4.5.1 The performance of the medication management system is regularly assessed (Developmental)

4.5.2 Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use (Developmental)

Criterion 2 - Documentation of patient information

4.6.1 A best possible medication history is documented for each patient

4.6.2 The medication history and current clinical information is available at the point of care

4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record

4.7.2 Action is taken to reduce the risk of adverse reactions

4.7.3 Adverse drug reactions are reported within the organisation and to the TGA.

4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings (Not Applicable for Dental Practices)

Criterion 3 - Medication management processes

4.9.1 Information and decision support tools for medicines are available to the clinical workforce at the point of care

4.9.2 The use of information and decision support tools is regularly reviewed

4.9.3 Action is taken to improve the availability and effectiveness of information and decision support tools

4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

4.10.2 Action is taken to reduce the risks associated with storage and distribution of medicines

4.10.3 The storage of temperature sensitive medicines is monitored (Not Applicable for Dental Services)

4.10.4 A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

4.10.5 The system for disposal of unused, unwanted or expired medications is regularly monitored

4.10.6 Action is taken to increase compliance with the system for storage, distribution and disposal of medications

4.11.1 The risks for storing, prescribing, dispensing and administration of high‑risk medicines are regularly reviewed

4.11.2 Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines

Criterion 4 - Continuity of medication management

4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines (Not applicable for Dental Services)

4.12.2 A current and comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care (Not applicable for Dental Services)

4.12.3 A current comprehensive list of medicines is provided to the receiving clinician during clinical handover (Not applicable for Dental Services)

4.12.4 Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current a comprehensive list of medicines during clinical handover (Not applicable for Dental Services)

Criterion 5 - Communicating with patients and carers

4.13.1 The clinical workforce provides patients with patient specific medicine information, including medication treatment options, benefits and associated risks (Developmental)

4.13.2 Information that is designed for distribution to patients is readily available to the clinical workforce (Developmental)

4.14.1 An agreed medication management plan is documented and available in the patient’s clinical record (Not Applicable for Dental Services)

4.15.1 Information on medicines is provided to patients and carers in a format that is understood and meaningful (Not Applicable for Dental Services)

4.15.2 Action is taken in response to patient feedback to improve medicines information distributed by the health service organization to patients (Not Applicable for Dental Services)

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.