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,
the first thing a nurse should do is to check on patient such taking the vital signs and doing observations as nursing care should be patient-centered. Second step would be informing the charge nurse about the error the patient’s present condition. Third would be informing the doctor about the medication error and the phone order to solve the problem. Open disclosure is the next step to assure the patient and family members that the health care team is undertaking risk management. Finally, document all the steps, findings and recommendations.
3. Brand names of medications were written. Ask the prescriber to include the generic names of the medications.
4. Some medications were not signed as given or were not noted as missed doses. Check the completeness of the chart during the handover before the outgoing shift goes off duty. If this was not seen during the handover, Inform the nurse manager about the unsigned medications.
5.
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
carers
Patients are informed about their options, risks and responsibilities for an agreed medication management plan.
In summary, in adhering to the regulatory and legislative requirements, the registered nurse should be equipped with the skills, knowledge and attitude on safe medication practice. This competency should be reviewed frequently and updated at least annually.