Medication Chart Audit
Most drug mistakes can be prevented through effective communication. It is therefore the responsibility of the healthcare team professionals (doctors, nurses, and pharmacist) to detect all possible factors that can lead to these occurrences.
Medication Chart Audit
Errors in the medication chart Actions and strategies to ensure ongoing safe administration
1. Incompleteness of the medication chart. The printed name of the prescriber and indication were not written. Ask the physician to tell you the name of the drug, the correct dosage, and what the drug is used for.
2. The patient’s medication allergies were incorrectly transcribed in the medications chart. If there was medication that was given to the patient that the patient is allergic to, …show more content…
The dosage of warfarin was not clear. The handwriting is illegible and there was tampering in the dose of the medication. Inform the nurse manager about the unclear handwriting and call the doctor to clear the order.
6. The prescriber and the transcriber did not write the complete order of the dose, route, and frequency of the medication Inform the nurse manager about this incident and remind the doctor about the completeness of the order.
Other Suggested strategies and recommendations
According to the Australian Commission on Safety and Quality in Health Care, there are criteria to achieve Medication Safety standard:
Criteria 1: Governance and systems for medication safety
This promotes prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines safely
Criteria 2: Documentation of patient information
Accurately record a patient’s medication history and medical history throughout admission.
Criteria 3: Medication management processes
Criteria 4: Continuity of medication management
The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.
Criteria 5: Communicating with patients and
Medication Chart Audit
Errors in the medication chart Actions and strategies to ensure ongoing safe administration
1. Incompleteness of the medication chart. The printed name of the prescriber and indication were not written. Ask the physician to tell you the name of the drug, the correct dosage, and what the drug is used for.
2. The patient’s medication allergies were incorrectly transcribed in the medications chart. If there was medication that was given to the patient that the patient is allergic to, …show more content…
The dosage of warfarin was not clear. The handwriting is illegible and there was tampering in the dose of the medication. Inform the nurse manager about the unclear handwriting and call the doctor to clear the order.
6. The prescriber and the transcriber did not write the complete order of the dose, route, and frequency of the medication Inform the nurse manager about this incident and remind the doctor about the completeness of the order.
Other Suggested strategies and recommendations
According to the Australian Commission on Safety and Quality in Health Care, there are criteria to achieve Medication Safety standard:
Criteria 1: Governance and systems for medication safety
This promotes prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines safely
Criteria 2: Documentation of patient information
Accurately record a patient’s medication history and medical history throughout admission.
Criteria 3: Medication management processes
Criteria 4: Continuity of medication management
The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.
Criteria 5: Communicating with patients and