RDHM Medication Audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Patient Identification

• Are identification labels attached to all pages in the patient record? <br>1) Patient name<br>2) Date of birth<br>3) UR number<br>4) Allergy status<br>

  Yes

  No

  N/A

• Was the patient's body weight documented?

  Yes

  No

  N/A

• Is there evidence that patient identification was confirmed before the medication was prescribed? <br>(YES if Surgical Safety Checklist paperwork used and box ticked for UR and patient's name, OR Timeout completed)

  Yes

  No

  N/A

• Has the allergies and ADR box been filled in? <br>(Signed, name printed, date, drug, reaction and initials, nil known or unknown box ticked)<br>If NO please add details of what is missing.

  Yes

  No

  N/A

• If an ADR was documented, are there alert stickers in the appropriate places?

  Yes

  No

  N/A

• If there was any previous ADR, was a similar class of medication prescribed at this visit?

  Yes

  No

  N/A

Medication History

• Does the patient have a documented Medication Management Plan?

  Yes

  No

  N/A

• Is the drug name and frequency documented for variable doses?

  Yes

  No

  N/A

Anticoagulants

• Is the patient currently taking any anti-coagulant medication?<br>Warfarin (Coumadin/Marevan) Apixaban (Eliquis) Rivaroxaban (Xarelto), Dabigatran (Pradaxa), heparins, enoxaparin (clexane)

  Safe

  At Risk

  N/A

Prescribing Medication

• Are the medication orders clear with dose to be given?

  Yes

  No

  N/A

• Are the medication orders clear with route to be given?

  Yes

  No

  N/A

• Are the medication orders clear with time given?

  Yes

  No

  N/A

PINCH -High Risk Medicines

• Are any PINCH drugs prescribed? <br>( Potassium, insulin, clexane/enoxaparin, heparin, morphine, pethidine, ketamine, alfentanil)

  Yes

  No

  N/A