MEDICATION CHART AUDIT
Various health care professionals have critical roles to play regarding medication safety since medication error occur at any point of the medication administration process. Even though they have different approaches in ensuring medications are prescribed, dispensed, and administered accordingly, they have the main goal to safeguard patients from such mistakes. Numerous institutions and/or organisations follow their own policy and protocol in effective medication management, unfortunately, poor systems and processes can contribute to this dilemma.
To discuss further, prescribing errors and medication administration errors are the primary contributors in medication error. In this task I was asked to identify five medication errors on the medication chart sheets.
Identified medication chart error:
Illegible handwriting and standard abbreviations not utilised.
Physicians must write in print and clear manner. They should also implement the standard guidelines in prescribing medications. On one hand, the nurse should clarify any confusion brought about by this.
Warfarin Education Record not filled out.
It must be ensured that accurate documentation is observed at all parts of medication management. The form must be completed with all the significant information that might affect the patient’s pharmacologic treatment.
Drug should have been withheld due to allergic reaction.
It was unclear if the medication was given right after an adverse reaction had occur. Nonetheless, patients should be monitored for any occurrence of adverse reaction. It must be reported and documented properly.
Use of brand name.
Physicians must use the generic name in prescribing medication to provide the nurses opportunity for easier familiarisation and so as to prevent confusion. At the event this scenario occurs, verify with the physician the generic name of the drug that should be given.
No route indicated.
There is an utmost significance in accurate documentation that should be acknowledged by any health care professional. The nurse must commit to memory the 7 Rights to medication administration to discern the disparity from the standard practice.
In summation, every health care provider must recognise the international standard protocols, and the organisation’s procedures and guidelines combined with acknowledgement of one’s responsibilities in medication management to minimize the risk of medication error. As a nurse, assertiveness can be advantageous in addressing discrepancies observed at any stage of the process being a patient-advocate. Secondly, self-appraisal can be beneficial as well in identifying the aspect that needs improvement. Thirdly, assure that accurate and comprehensive documentation of each aspect related to medical management is overseen. Finally, local protocols and policies about safety medication administration should be evaluated regularly to address any lapses.