NSW Government Health Medication Audit Chart (NIMC)

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AUDIT OUTLINE
1. AUDIT TOPIC
The explicit documentation being audited is the NSW Government Health Medication Chart (MR71) known as the adult National Inpatient Medication Chart (NIMC). The adult NIMC was introduced to support the standardization of medication legislation with respect to storage, administration and documentation of medications and safeguard patients against prescription errors and ensure privacy of information (Atik, 2013). According to the Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012), the NIMC is useful in verifying patients susceptible to adverse drug reactions (ADR’s) and allergies as well as identifying medications by their generic name and intended use as well as clearly displaying the printed …show more content…

Most importantly the adult NIMC is used to establish the ‘five rights’ of the individual being first and fore mostly the right patient, right dose, right medication, right route and right time (Parker, Kucia, Fedoruk, Laws & Phillips, 2012). The audit tool employed to determine performance indication levels below 100% for the fore mentioned parameters will be the Medication Audit Chart (MAC) tool. The audit will focus on the relevance of correct medication documentation to the adult NIMC to ensure patients are provided with a quality of care that ensures safety and efficacy as well as supporting partnerships between health professionals and their patients to maintain person-centered care in relation to the administration of medications (National Inpatient Medication Chart 2014 National Audit Report, (NIMC National Audit Report), 2015). The audit will also include reviewing the correct use of abbreviations, that target INR for Warfarin is acknowledge by 2 registered nurses as well as their presence being required for the preparation and administration of all S4 and S8 medications including injectables. The audit data was collected from five adult patients recovering on an orthopaedic …show more content…

Continuity of Medication Management
Sub-Standard:
4.12 Patients, their carers, and clinicians are provided with a comprehensive medication list during handover and transfer of care and when medications are updated
Identifying patients and their current medications occurs when documentation in the NIMC is accurately completed and also allows for correct handover of patient information to ensure patient safety at the end of care (ACSQHC, 2012).

STANDARD 5: PATIENT IDENTIFICATION AND PROCEDURE MATCHING
Identification of Individual Patients
Sub-Standard:
5.1 It is essential that there are three approved identifiers for the recognition of patients to prevent medication errors occurring. This includes identifying the intended regimen and that the meticulous compliance of medication administration is adhered to by carers and other healthcare workers involved with the patients care. The application of accurately documenting patient information and medication administration into the adult NIMC is directly related to patient safety (ACSQHC,

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