Information
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Version 2 * National Standard 4 - Medication Safety Standard
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Client / Site
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Conducted on
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Conducted by:
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Personnel who participated in the gathering of specific evidence for this Standard
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Address / Location
Standard 4 - Audit Report
CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT TO SUPPORT MEDICATION MANAGEMENT
Integrating clinical governance
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4.1 Clinicians use the safety and quality systems from the Clinical Governance Standard when:<br>a. Implementing policies and procedures for medication management<br>b. Managing risks associated with medication management<br>c. Identifying training requirements for medication management
Applying quality improvement systems
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4.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:<br>a. Monitoring the effectiveness and performance of medication management<br>b. Implementing strategies to improve medication management outcomes and associated processes<br>c. Reporting on outcomes for medication management
Partnering with consumers
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4.3 Clinicians use organisational processes from the Partnering with Consumers Standard in medication management to:<br>a. Actively involve patients in their own care<br>b. Meet the patient’s information needs<br>c. Share decision-making
Medicines scope of clinical practice
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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
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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
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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
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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
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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
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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
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4.10 The health service organisation has processes:<br>a. To perform medication reviews for patients, in line with evidence and best practice<br>b. To prioritise medication reviews, based on a patient’s clinical needs and minimising the risk of medication-related problems<br>c. That specify the requirements for documentation of medication reviews, including actions taken as a result
Information for patients
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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
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4.12 The health service organisation has processes to:<br>a. Generate a current medicines list and the reasons for any changes <br>b. Distribute the current medicines list to receiving clinicians at transitions of care<br>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
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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
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4.14 The health service organisation complies with manufacturers’ directions, legislation, and jurisdictional requirements for the:<br>a. Safe and secure storage and distribution of medicines<br>b. Storage of temperature-sensitive medicines and cold chain management<br>c. Disposal of unused, unwanted or expired medicines
High-risk medicines
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4.15 The health service organisation:<br>a. Identifies high-risk medicines used within the organisation<br>b. Has a system to store, prescribe, dispense and administer high-risk medicines safely
