MEDICATION MANAGEMENT MODULE
Service name:_____________________________________________
Date completed:_________________________________
INTRODUCTION: As part of HDANZ’s onTrack programme, the following questionnaire is intended to provide you with a self-assessment review of your
service, in relation to key areas of service delivery for your business planning and quality/risk system. Note that this question sub-set is intended as a
guide only and reflects the relevant sector standards and possible good practices. The self-assessment allows you to identify areas that are working well
(Yes) and areas that may need further preparation for your quality system and service delivery (No). There is an action plan template at the end of the
question set. For any “No” responses you can copy and paste that into the action plan and monitor its completion.
Ref #
Self-assessment questions
1.1
Does the service have policies and procedures that are based on recognised good practice and guidelines for the management
of medicine administration relevant to their service setting?
1.2
Is there a medication profile for each resident/consumer/service user signed by the person's medical practitioner?
1.3
As they arrive, are medicines checked and verified against the person's medication profile?
1.4
Are medicines stored in a locked room or locked cupboard that is below 25C?
1.5
Are medicines kept in their original dispensed containers until immediately prior to administration?
1.6
Is a refrigerator available for medicines, with daily temperature checks and a weekly record of temperatures?
1.7
If you have Controlled Drugs, are they kept in a locked safe or locked cupboard accessible only to senior staff?
1.8
Is there one senior staff member responsible for drug administration on each duty and do they hold the keys to the medicines?
1.9
Is medicine expiry dates checked each month and expired or discontinued medicines returned to the pharmacy for disposal?
1.10
Do your policies and procedures identify staff medicine management responsibilities?
1.11
Are staff who administer medicine trained at least annually and recorded as competent for the role?
1.12
Is medication competency of each staff member reviewed at least annually?
1.13
Are the prepared daily doses checked against the Resident Medication Profile and entered on the Medication Administration
Record for signing off as the dose is administered? (This should use the original dispensed container or unit does pack to
administer and if this is not possible a suitable alternative system must ensure the right dose is administered to the right person
Yes
No
Comments
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at the right time).
1.14
Are internal audits or reviews completed of the medicine administration system, including direct observation of staff for
administration procedures?
1.15
Are allergies or sensitivities recorded, including if "nil" allergies?
1.16
Is there a documented procedure for the management of an adverse reaction?
1.17
Are adverse reactions or errors documented and investigated as an incident?
1.18
Are there procedures in place for the self-administration of medicines and are they adhered to?
1.19
For self-medication, is there a locked cupboard or drawer used for storage in the resident's room?
1.20
For self-medication, are these checked weekly and do senior staff and the doctor or RN assess the ability to self-medicate at
least 3 monthly?
1.21
Are household remedies (standing orders) authorised on the Resident Medication Profile.
1.22
Is PRN medication authorised, includes reasons for giving, administered appropriately and documented?
1.23
Are medication charts completed correctly and reviews by the medical practitioner documented at least 3 monthly?
1.24
If relevant, where there is controlled drug medicine use is there: 1. A controlled drug register, and 2. Does regular checking
(including register checks) occur, and 3. Is there secure safe storage, and 4. Do signing charts align with controlled drug
register?
1.25
Is there a current agreement in place with the pharmacy?
2
ACTION PLAN: MEDICATION MANAGEMENT MODULE
Ref #
Self-assessment questions
(for “No” responses above)
Improvement action to be taken
Due
date
Person
responsible
Date
completed
(Add additional rows as necessary)
3