were not sure if they had an annual appraisal taken within the last 12 months. Criterion 1.3.12.1 PA Policies and procedures for medicine management were Safe medication Ensure all High reviewed and meet requirements. All staff administering management and medication is A medicines management system is and checking of medications have completed medication disposal of sharps administered safely implemented to manage the safe and competency. A medicine administration round was processes as per as prescribed and appropriate prescribing, dispensing, observed on the day of audit, however best practice was policy and procedure sharps are disposed administration, review, storage, not always followed. Electronic charting evidenced a are not being followed. of appropriately. disposal, and medicine reconciliation in resident prescribed insulin via a device. A ‘flexipen’ order to comply with legislation, registered nurse was observed to draw insulin from a protocols, and guidelines. prescribed insulin flexipen with another needle and 1 days syringe. The amount of insulin drawn was checked by the health care assistant as correct. The registered nurse administered the medication to the resident and acknowledged on the electronic device. A discussion with the registered nurse, clinical nurse manager and facility manager were unable to clarify why this specific practice occurred. Correct needles for the flexipen were made available, the disposal needle and syringes were removed from the medication trolley and best practice was discussed with the afternoon registered nurse on duty by the facility manager. On day two of audit the clinical nurse manager stated that having spoken to the facility manager that might be best to return to the ‘it practice of introduced syringe and needle as she was unsure of how to administer insulin from the flexipen and safe practice when changing the flexipen disposable needles’. A phone call to the pharmacist confirmed that this was not best practice. At the time of audit, two used and unsheathed needles connected to syringes were found in the medication trolley. The registered nurse at the request of the clinical nurse manager disposed of the needles and syringes appropriately. A sharps bin was placed in the medication trolley. An incident form was completed. The facility manger has stated that a corrective action plan will be developed to ensure that interventions are
were not sure if they had an annual appraisal taken within the last 12 months. Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA High Policies and procedures for medicine management were reviewed and meet requirements. All staff administering and checking of medications have completed medication competency. A medicine administration round was observed on the day of audit, however best practice was not always followed. Electronic charting evidenced a resident prescribed insulin via a ‘flexipen’ device. A registered nurse was observed to draw insulin from a prescribed insulin flexipen with another needle and syringe. The amount of insulin drawn was checked by the health care assistant as correct. The registered nurse administered the medication to the resident and acknowledged on the electronic device. A discussion with the registered nurse, clinical nurse manager and facility manager were unable to clarify why this specific practice occurred. Correct needles for the flexipen were made available, the disposal needle and syringes were removed from the medication trolley and best practice was discussed with the afternoon registered nurse on duty by the facility manager. On day two of audit the clinical nurse manager stated that having spoken to the facility manager that ‘it might be best to return to the practice of introduced syringe and needle as she was unsure of how to administer insulin from the flexipen and safe practice when changing the flexipen disposable needles’. A phone call to the pharmacist confirmed that this was not best practice. At the time of audit, two used and unsheathed needles connected to syringes were found in the medication trolley. The registered nurse at the request of the clinical nurse manager disposed of the needles and syringes appropriately. A sharps bin was placed in the medication trolley. An incident form was completed. The facility manger has stated that a corrective action plan will be developed to ensure that interventions are Safe medication management and disposal of sharps processes as per policy and procedure are not being followed. Ensure all medication is administered safely as prescribed and sharps are disposed of appropriately. 1 days