Medication audit tool with action plan
Audit of medication on houses and within nursing
What does this form include?
This form contains 24 sections:
During this audit, one student record should be used as a sample during the audit process. If any err
1.1 Total number of available beds
1.2 Total number of beds occupied?
1 - Overview
- 1.3 Has the previous audit been reviewed and signed off?
1.4 How many corrective actions were raised during the last audit?
2 - Management of Medication
- 2.1 Is there an up to date list of all staff who administer drugs complete with sample signatures?
- 2.2 Is there a written procedure for the administration of drugs in use?
- 2.3 Have all staff who administer medication been trained and assessed as competent?
- 2.4 Is a copy of the BNF available and is this under twelve months old?
- 2.5 Is there a policy in place for:Obtaining, Receipt and Storage of medicinesHandling and Administration of medicinesMonitoring of medicinesDisposal of medicinesHandling and Review of incidents / errors / near missesHomely RemediesCovert medicationSocial LeaveSelf-administration of medication
- 2.6 Has a cosh assessment been completed for hazardous substances e.g. Cytotoxics, oxygen?
2.7 Further comments / observations for Management of Medication
3 - Ordering of Medication
- 3.1 Do you have a specific named contact at the surgery and at the pharmacy where medication is ordered?
- 3.2 Are there designated members of the team who deal with the ordering of medication?
- 3.3 Are all requests for prescriptions auctioned in a timely manner?
- 3.4 Is there a procedure in place for obtaining emergency supplies of medicines? E.g out of hours, bank holidays.
3.5 Further comments / observations:
4 - Medication and Administration
- 4.1 Is a monitored dosage system in place and if so is it operated satisfactorily in your home?
- 4.2 Are all medicines clearly labelled in accordance with requirements?
- 4.3 Are all medicines within their expiry date?
- 4.4 Does the strength of the medication correspond with that written on the treatment sheet?
- 4.5 Are all medicines appropriately signed for at the time of administration?
- 4.6 Do MAR sheets have a means of identifying the patient? E.g photograph and room number?
- 4.7 Does the MAR sheet tally with the amount of medicine in stock?
- 4.8 If prescription states take 1 or 2 tablets, does the treatment sheet identify clearly wether 1 or 2 are administered?
- 4.9 Do the instructions state 'as directed'? Are instructions clarified with GP before administration?
- 4.10 If medication is PRN does it state in what circumstances it is to be administered?
- 4.11 Is a record made of any doses omitted with a reason why? (I.e. appropriate coding used to acknowledge reason)
- 4.12 Are all external medications recorded when administered or applied?
- 4.13 Are eye drops and insulin dated when opened and discarded after one month?
- 4.14 Is there evidence of regular medication reviews?
- 4.15 Where additional knowledge is required for administration e.g. Insulin, PEG tubes, rectal products have staff been trained in these techniques including formal assessment of competency?
4.16 Further comments / observations:
5 - Labelling of Medicines
- 5.1 Do all service users have their own individual supply?
- 5.2 Is each medication clearly labelled by a pharmacist or GP?
- 5.3 Are labels in original condition and not changed by hand?
- 5.4 Is the medication labelled, not just on the outer box (e.g. Labels on tubes and not just the box)?
- 5.5 Is a patient information leaflet available for each medicine store at the home?
5.6 Further comments / observations:
6 - Storage of Medication
- 6.1 Is there a secure and designated storage area for medicines and medicine trolleys?
- 6.2 Are the keys for the medical cupboard and CD cupboard kept separate from other keys?
- 6.3 Is access to these keys and medical storage facilities restricted to authorised staff only?
- 6.4 Are external medications stored in a separate locked cupboard or on a separate shelf in the storage area?
- 6.5 Are all medicinal products, dressings and osteomyelitis products stored off the floor at all times?
- 6.6 When new medication arrives atnthenhome is there a stock rotation system in place?
- 6.7 Are stock levels of reserve drugs acceptable and appropriate for individual use?
- 6.8 Are discontinued / expired medicines removed from the trolley promptly?
- 6.9 Are medicines no longer required returned to pharmacy promptly?
- 6.10 Are all medicines returned to the pharmacy signed for by the accepting pharmacy?
- 6.11 Are all medicines stored in locked cupboards / trolleys? Is the trolley anchored to the wall?
- 6.12 Are there any medications requiring storage in a fridge and if so are they stored correctly?
- 6.13 Is there a maximum / minimum thermometer in the fridge?
- 6.14 Is the fridge regularly cleaned and defrosted?
- 6.15 Is the temperature of the fridge monitored and recorded on a daily basis?
- 6.16 Are staff aware of the procedure to follow if the fridge temperature is outside the 2-8 deg. Range?
- 6.17 Is storage satisfactory for oxygen cylinders and in accordance with the Health & Safety regulations?
- 6.18 Is a warning notice displayed at each location where oxygen is stored or in use?
6.19 Further comments / observations:
7 - Controlled Drugs
- 7.1 Does the controlled drug cupboard comply with legislative requirements? E.g. Is it a locked cupboard within a locked cupboard?
- 7.2 Is a dedicated controlled drug register available?
- 7.3 Do stock levels held balance with the controlled drug register?
- 7.4 Are all controlled drug administrations witnessed and are two signatures obtained?
- 7.5 Care homes providing personal care: Are CD's administered and witnessed by a designated and appropriately trained member of staff?
- 7.6 Care homes providing nursing care: Are CD's administered by a registered medical,practitioner or registered nurse?
- 7.7 Is a separate page used for each person and each CD?
7.8 Further comments / observations:
8 - Staff Training
- 8.1 Have all staff who handle medication received training in the safe handling of medicines?
- 8.2 Is all staff training documented?
- 8.3 Is training accredited and does it cover the skills for Care Knowledge Set for Medication?
- 8.4 Is there a refresher course for staff?
- 8.5 Is there a procedure in place to deal with all relevant medicine related patient safety communications issued via alert systems within the required timescales?
- 8.6 Is there a procedure in place to communicate relevant information within the administration team?
- 8.7 Is there a procedure in place for reporting incidents, errors and omissions?
Audit Criteria and Additional Comments:
- Number of records inspected during this audit.
Details of records inspected during this audit
How many corrective actions were raised from this audit?
Audit Completed By:
Review Date Date
Audit Reviewed By:
Use this template