Are identification labels attached to all pages in the patient record?
1) Patient name
2) Date of birth
3) UR number
4) Allergy status
Was the patient's body weight documented?
Is there evidence that patient identification was confirmed before the medication was prescribed?
(YES if Surgical Safety Checklist paperwork used and box ticked for UR and patient's name, OR Timeout completed)
Has the allergies and ADR box been filled in?
(Signed, name printed, date, drug, reaction and initials, nil known or unknown box ticked)
If NO please add details of what is missing.
If an ADR was documented, are there alert stickers in the appropriate places?
If there was any previous ADR, was a similar class of medication prescribed at this visit?
Does the patient have a documented Medication Management Plan?
Is the drug name and frequency documented for variable doses?
Is the patient currently taking any anti-coagulant medication?
Warfarin (Coumadin/Marevan) Apixaban (Eliquis) Rivaroxaban (Xarelto), Dabigatran (Pradaxa), heparins, enoxaparin (clexane)
Are the medication orders clear with dose to be given?
Are the medication orders clear with route to be given?
Are the medication orders clear with time given?
Are any PINCH drugs prescribed?
( Potassium, insulin, clexane/enoxaparin, heparin, morphine, pethidine, ketamine, alfentanil)