Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1) 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. Attainment and Risk: PA Moderate Evidence: The service uses individualised medication blister for regular, time” medications and PRN medications. Three medication rooms are viewed (rest home, hospital and “odd special care unit) and one medication cupboard (serviced apartments). All medications rooms are secure. Medications trolleys are locked. Contents are all within expiry dates and eye drops are dated on opening. Expiry dates of all medications are checked monthly. There are no gaps identified on the 18 medication sighing sheets reviewed. PRN medications have the time of administration on the signing sheet. Controlled drugs are signed by two persons. Dietary supplements, antibiotics and short course have signing sheets. Alert labels include for second pack”, course medications” and “look “short drugs”. “controlled Finding: (i)There is no documented evidence of medications checked against the medication chart on delivery. (ii) There is transcribing on four non-packaged signing sheets (two special care unit and two rest home). Corrective Action: (i)Ensure medications are checked against the medication chart on delivery. (ii) Ensure there is no transcribing. Timeframe (days): 60 (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each they manage. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1) 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. Attainment and Risk: PA Moderate Evidence: The service uses individualised medication blister for regular, “odd time” medications and PRN medications. Three medication rooms are viewed (rest home, hospital and special care unit) and one medication cupboard (serviced apartments). All medications rooms are secure. Medications trolleys are locked. Contents are all within expiry dates and eye drops are dated on opening. Expiry dates of all medications are checked monthly. There are no gaps identified on the 18 medication sighing sheets reviewed. PRN medications have the time of administration on the signing sheet. Controlled drugs are signed by two persons. Dietary supplements, antibiotics and short course have signing sheets. Alert labels include “look for second pack”, “short course medications” and “controlled drugs”. Finding: (i)There is no documented evidence of medications checked against the medication chart on delivery. (ii) There is transcribing on four non-packaged signing sheets (two special care unit and two rest home). Corrective Action: (i)Ensure medications are checked against the medication chart on delivery. (ii) Ensure there is no transcribing. Timeframe (days): 60 (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each they manage. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
AuditSummary_PRMS_CommunicatePublish_000000819002.docx