Standard 4 - Audit Report

CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT TO SUPPORT MEDICATION MANAGEMENT
Integrating clinical governance

4.1 Clinicians use the safety and quality systems from the Clinical Governance Standard when:
a. Implementing policies and procedures for medication management
b. Managing risks associated with medication management
c. Identifying training requirements for medication management

Applying quality improvement systems

4.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
a. Monitoring the effectiveness and performance of medication management
b. Implementing strategies to improve medication management outcomes and associated processes
c. Reporting on outcomes for medication management

Partnering with consumers

4.3 Clinicians use organisational processes from the Partnering with Consumers Standard in medication management to:
a. Actively involve patients in their own care
b. Meet the patient’s information needs
c. Share decision-making

Medicines scope of clinical practice

4.4 The health service organisation has processes to define and verify the scope of clinical practice for prescribing, dispensing and administering medicines for relevant clinicians

DOCUMENTATION OF PATIENT INFORMATION
Medication reconciliation

4.5 Clinicians take a best possible medication history, which is documented in the healthcare record on presentation or as early as possible in the episode of care

4.6 Clinicians review a patient’s current medication orders against their best possible medication history and the documented treatment plan, and reconcile any discrepancies on presentation and at transitions of care

Adverse drug reactions

4.7 The health service organisation has processes for documenting a patient’s history of medicine allergies and adverse drug reactions in the healthcare record on presentation

4.8 The health service organisation has processes for documenting adverse drug reactions experienced by patients during an episode of care in the healthcare record and in the organisation-wide incident reporting system

4.9 The health service organisation has processes for reporting adverse drug reactions experienced by patients to the Therapeutic Goods Administration, in accordance with its requirements

CONTINUITY OF MEDICATON MANAGMENT
Medication review

4.10 The health service organisation has processes:
a. To perform medication reviews for patients, in line with evidence and best practice
b. To prioritise medication reviews, based on a patient’s clinical needs and minimising the risk of medication-related problems
c. That specify the requirements for documentation of medication reviews, including actions taken as a result

Information for patients

4.11 The health service organisation has processes to support clinicians to provide patients with information about their individual medicines needs and risks

Provision of a medicines list

4.12 The health service organisation has processes to:
a. Generate a current medicines list and the reasons for any changes
b. Distribute the current medicines list to receiving clinicians at transitions of care
c. Provide patients on discharge with a current medicines list and the reasons for any changes

MEDICATION MANAGEMENT PROCESSES
Information and decision support tools for medicines

4.13 The health service organisation ensures that information and decision support tools for medicines are available to clinicians

Safe and secure storage and distribution of medicines

4.14 The health service organisation complies with manufacturers’ directions, legislation, and jurisdictional requirements for the:
a. Safe and secure storage and distribution of medicines
b. Storage of temperature-sensitive medicines and cold chain management
c. Disposal of unused, unwanted or expired medicines

High-risk medicines

4.15 The health service organisation:
a. Identifies high-risk medicines used within the organisation
b. Has a system to store, prescribe, dispense and administer high-risk medicines safely

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.