Clinical Audit Assignment. Introduction. There are many benefits in carrying out a clinical audit. It allows nurses to evaluate the care they are giving, encourages them to keep better records, focuses on the care given rather than the care giver themselves and achieves a feasible quality of nursing care (Harmer and Collinson 2005). According to Clement (2012), a nursing audit can be defined as a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. There are different types of nursing audits to choose from. A nursing management audit, which is a structured audit that concentrates on the administrative aspect of nurses responsibilities. A retrospective audit which …show more content…
Drug Kardexes were gathered and audited under certain criteria in order to identify potential risk areas in drug prescribing and administration, and also to provide ways in which these risks can be reduced or eliminated and reinforce drug management policies’ and guidelines. NICE (2002) audit cycle will be applied to this assignment to provide an acceptable framework (Appendix 1). Step 1: Preparing for Audit. The first step in the audit process is to identify which type of audit is to be carried out. In this case the concurrent review was chosen. As discussed previously in the assignment it was decided that drug kardex documentation would be audited. A drug kardex, also known as drug prescription or drug script is defined by the World Health Organisation (2002) as ‘’an instruction from the prescriber to the dispenser’’. In this instance the prescriber will be identified as any doctor in the hospital setting with prescriptive authority and the dispenser can be identified as any registered general nurse. For this Audit the author took the following steps in developing questions for the Audit tool as guided by The National Institute for Clinical Excellence …show more content…
In order to correctly identify the right patient this addressograph should contain the patients name, address, date of birth and unique identity umber. On administration of medication these details should be cross checked between the patients’ armband and their drug kardex. These details should also be checked with the patient on admission to ensure that they are correct. To further protect the patient, their allergy status should be clarified and documented on the kardex. If the patient is unable to verify this for themselves a family member, carer or General Practitioner may be able to provide this information. This should also be asked to the patient on every drug round as new drugs can be described at any time. The patients’ weight should be recorded on the kardex also as certain drugs are given according to weight such as Infliximab and their weight will determine the required
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A patient is admitted to Nightingale Community Hospital to the surgical unit following an infection to a post-op wound. There were several deficiencies found on the patient’s tracer audit once the patient was admitted to the hospital. One deficiency that was found was that the patient was given medication related to pain and the patient was not reassessed properly per Joint Commission Standards (JC). The deficiency found is within the pain assessment policy of the hospital.
It is important to follow any guidelines and leaflets in medication, as this helps the safe administration of all medicines. It is also important to find out if a person has already taken medication prior to the care support worker giving them any. This is to ensure that you do not overdose the individual. A service user usually has a MARS sheet where the medication that is administered in signed off by the care worker that last administered it to them, so that the care support worker can clearly see that last time the medication was administered to service user, and when they are next due to have the medicine.
By creating this comprehensive list of the medication plan given to the patient, the hospital pharmacist can then send this information to the community pharmacist and make sure that the information is held up to date. This would allow for a smoother transition for the patient and it would allow the patient to be more informed of their medications. The pharmacist is “poised to play an important role in improving medication management during transitions of care and reducing readmission rates” so the pharmacist should play a more active role to help ensure the best therapy for the patient (7). The pharmacist should ultimately design an ideal system for Medication Reconciliation to help reduce medication errors and better inform patients on ADEs to prevent any unnecessary medical
The given reason being nurses are not likely to report the errors and only when clinincal consequences arise are they discovered. The focus of the Dalmolin, Rotta, & Goldim, (2013) study was to evalualte the medication errors for the types, seriousness, and medication groups involved. The study was conducted at the Hospital de Clinicas de Porto Alegre(HCPA) between January 2010 and December 2011. The study was conducted using a retrospective and cross-sectional study process. The study used data on medication errors, that was submitted to the Group for Safe Use of Medications.
I will need to observe the medication administration record, Control drugs record, generic & brand names documents and risk assessment documents. This is important in order to avoid errors while dispensing a medication. Knowing all this beforehand will enable me know the type of medication written on the prescription and where to get them from (fridge, cupboard or the shelves). This knowledge will promote and help to maintain independence in the appropriate way to handle prescription.
In the medication administration management process, the prescribers (Physician, Nurse Practitioner, Physician Assistant), orders the medication and treatment for patient. The order is signed and send to the pharmacist. The pharmacist received the order, review, interprets the order, detect therapeutic incompatibilities, dispense by labeling and packing for administration. The last management process is the nurse. The nurse duty is to review the received medication from the pharmacist then administer the medication to the patient.
In care settings the currently legislations, guidelines policies and protocols relevant to the administration of medication would be: - The misuse of drugs act 1971 - The Medicines Act 1968 - Care Standards Act 2000 - The Health and Social Care Act 2001 The Control of Substances Hazardous to Health Regulations 1999 - The RPS Handling Medicines in Social Care Guidelines The recording, storage, administration and disposal of medication must be adhered by employees in accordance with the current policies and procedures. The policies are in place to protect everyone - training must be undertaken or up-to-date before support workers can administrate any medication.
In 2007, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) acknowledged that reconciliation errors compromise the safety of drug use and recommended hospitals to develop a system for obtaining patients’ complete pharmacotherapeutic records, to ensure they receive the necessary drugs for the new
The clinical pharmacology unit in the University Hospital of Verona Italy have published a journal on medication errors specifically focusing on prescribing faults and prescription errors. In this journal they have stated that “any step in the prescribing process can generate errors which can be fatal and can affect patients safety and quality of healthcare”. Poor handwriting, bad communication between doctors and nurses and poor knowledge of drug and its side effects are all listed in this journal as errors within the prescribing process. The author of the journal suggests that “immediate review of prescriptions should be performed with the assistance of a hospital pharmacist” to prevent errors in the prescription stage and to increase patient safety. Errors within administration are also common.
Medication error is not something new in healthcare service. Researchers had identified medication error is the high numbers of incidents involving nursing practice. Thus, a proper and well designed organizational system should be in place for the process of administration of medication to minimize and prevent errors. Medication happens when there is a failure in the system. To my surprise when I did the write up for this paper I had came across many clinical practice guidelines on medication safety.
5 NURSING PROCESS The nursing process is a series of organized steps designed for nurses to provide excellent care. Learn the five phases, including assessing, diagnosing, planning, implementing, and evaluating. 5:1 Personnel Context As a nurse can make a huge difference in the health of my patients by many methods.
Without caution, it can be easy for nurses to make numerous amounts of errors when performing medication administration. These errors can potentially be deadly, or cost the hospital a lot of money. It is always important for any nurse administering medicine to abide by the six rights of medication administration. When nurses are working with medications the nurse needs to be focused on the task at hand. It is ultimately up to the nurse to provide their patient with the highest standard of quality
One method is to improve both verbal and written instructions and medicinal directions, making the indications and doctor’s aspirations clear and concise for the patient to understand and subsequently adhere to. The consultation room in a community pharmacy is a vital point of contact with patients in order to effectively counsel the patient on the importance of adhering strictly to their medication regimen and formally educate them on aspects relating to their condition and health. If a health care professional deems it necessary, they can consider contacting the patient’s family to create a wider support group for monitoring the patient’s adherence. The simplification of dosing regimens, blister packing medication and prescription refill reminders are other highly effective ways of standardising adherence to medication for patients, particularly for older
AAS- Medical Office Procedures Week 2 Discussion Judy Potts Explain why pharmaceutical representatives leave samples of expensive medications with physicians. Pharmaceutical representatives, show the physicians the newest drugs on the market, to drum up business for the pharmaceutical companies. The representatives leave samples of the products, In hopes that the doctor will strat prescribing their new name brand products for his patients instead of generic drugs. Also, in some cases, the patients are not financially able to purchase a new drug not knowing if it will help with their disease. The clinic 's management staff will determine whether they will be except the newest medication samples from the representative.