Medication Management Audit Checklist Template

What the Medication Management Audit Checklist Covers

1. 1
   Phase 1

   Phase 1: Plan the Audit

   5 tasks

   Agree what the audit covers and read the records before the visit. Answer the questions on the first task first: they show the controlled drugs, fridge, covert administration and self-administration checks that apply, and the notes for your setting and country. Every due date counts from the audit start date.

   • Record the service, the auditor and the manager who signs off — the care home, ward or clinic audited, the audit start date, the setting and country, whether controlled drugs, fridge medicines, covert administration or self-administration apply, and the auditor, the manager who signs off and the medicines lead who owns the actions
   • Agree the scope, sample and visit date with the manager — which sections apply, how many people’s medicines records to sample, which medicines round to observe, and the visit date
   • Pull the last audit and its open actions — which actions were closed, which slipped, and which sections were rated lowest last time
   • Choose the audit tool and the standards to audit against — your own medicines policy first, then the law and guidance for your country and setting, using your organisation’s tool or one from your pharmacy or local medicines optimisation team
   • Gather the medicines records before the visit — the medicines policy, the sampled medicines administration records and care plans, the controlled drugs register, room and fridge temperature records, order and delivery records, returns and disposal records, and incident and training records since the last audit
2. 2
   Phase 2

   Phase 2: Policy, Training & Competence

   5 tasks

   Check the paperwork behind safe medicines handling before the visit: the policy, who is trained and who has been assessed as competent. NICE SC1 lists the written processes a care home medicines policy should include, and asks for an annual review of each person’s medicines competence.

   • Check the medicines policy is current and complete — reviewed on the date it promised, based on current law and guidance, and covering ordering, receiving, storing, administering, records, controlled drugs, covert administration, self-administration, transfers, incidents and disposal
   • Check every member of staff who handles medicines is trained — induction and medicines training recorded for each one, including bank and agency staff, plus training for any specialist technique they use, such as inhalers, eye drops or feeding tubes
   • Check competency assessments are in date — each member of staff assessed as competent before they first gave medicines, and their knowledge, skills and competence reviewed every year, or sooner after a medicines incident
   • Check the homely remedies process, if one is used — each non-prescription product named with who it is for and not for, the dose, the maximum daily dose, where it is recorded and when to refer to a GP, and signed by each member of staff who gives it
   • Check safety alerts and medicines changes reach staff — national patient safety alerts actioned within the time set, and changes to people’s medicines from letters, emails and phone calls recorded and acted on
3. 3
   Phase 3

   Phase 3: Ordering, Receipt & Storage

   8 tasks

   Medicines must be stored securely, with only authorised staff having access, and in the conditions the manufacturer sets. No law sets one temperature range for every medicine: the range comes from each product’s own instructions. The fridge check appears when the service keeps medicines in a fridge.

   • Check how medicines are ordered — the service orders from the prescriber itself rather than leaving it to the pharmacy, at least two members of staff are trained to order, and a record is kept of every order
   • Check deliveries are checked against the order — each delivery checked against the record of the order, with missing or wrong items followed up so nobody goes without a medicine
   • Check medicines are locked away and keys are controlled — trolleys, cupboards and rooms locked when not in use, keys held by authorised staff only, spare keys stored securely, and nothing but medicines kept in medicines storage
   • Check the medicines room temperature record — a reading on every day the policy asks for, readings within the range the manufacturers set for the medicines stored there, and action recorded whenever a reading was out of range
   • Check the medicines fridge and its temperature record — shown when medicines are kept in a fridge: a fridge used only for medicines and locked or in a locked room, current, minimum and maximum readings recorded every day, the thermometer reset after each reading, and what was done when a reading was out of range
   • Check external medicines are kept apart from internal medicines — creams, ointments and lotions stored separately from tablets and liquids, each labelled for the person it was prescribed for, and any kept in people’s rooms covered by a risk assessment
   • Check expiry dates and opened-date labels — no expired stock in use, and the date of opening written on any product that expires sooner once opened, as its instructions say, such as eye drops, liquids and creams
   • Check each person’s medicines are used only for them — no medicines borrowed between people, ‘when required’ medicines kept in their original packs, and emergency medicines such as an adrenaline auto-injector quick to reach and in date
4. 4
   Phase 4

   Phase 4: Medicines Administration Records

   8 tasks

   Read each sampled medicines administration record (MAR) against the care plan and the stock. Refer to people by room number or initials in the audit record. The covert administration check appears when anyone is given medicines without their knowledge.

   • Check each sampled MAR has the person’s details and allergies — full name, date of birth, weight where appropriate, the GP, and any known allergies with the type of reaction, matching the care plan
   • Check for gaps, unexplained codes and unsigned doses — every dose signed for once it was taken, or coded with a reason when it was not, codes explained on the chart, and mistakes corrected with a single line, a signature, the date and the time
   • Check refused and missed doses were followed up — each refusal recorded, the prescriber told when the policy says so, and a pattern of refusals or missed doses raised with the GP or pharmacist
   • Check ‘when required’ (PRN) records — a PRN plan for each medicine saying what it is for, the dose, the maximum in a day and the minimum gap between doses, and each dose recorded with the reason, the amount given and whether it worked
   • Check variable and time-sensitive doses — the dose actually given recorded when a range is prescribed, and medicines the prescriber or pharmacist has marked as time-sensitive given at the time set
   • Check handwritten entries and changes to the MAR — new handwritten records made only in exceptional circumstances, by a trained member of staff, and checked and signed by a second before first use, with the source of each change recorded
   • Check records for patches and creams — where each patch was applied and when the old one was removed, the site changed as the instructions say, and cream records showing what was applied, where and by whom
   • Check covert administration is lawful and recorded — shown when anyone is given medicines covertly: a mental capacity assessment, a best-interests decision agreed with the prescriber, a pharmacist and a family member or advocate, a plan for each medicine with pharmacist advice on how to give it, a review date, and the MAR showing which doses are given covertly
5. 5
   Phase 5

   Phase 5: Administration Observed

   4 tasks

   Watch at least one medicines round as it happens. Record what you saw, not what staff say they usually do, and ask about anything you could not judge by watching. The self-administration check appears when anyone looks after their own medicines.

   • Observe a medicines round — the right person, medicine, route, dose and time checked for each dose, the person’s right to refuse respected, the record made as soon as the dose is taken, each person finished before the next, and interruptions kept to a minimum
   • Check ‘when required’ medicines are offered when needed — staff ask about pain and other symptoms and offer PRN medicines when the person needs them, not only at round times, including people who cannot ask
   • Check self-administration risk assessments and storage — shown when anyone looks after their own medicines: a risk assessment for each person, reviewed when it says, their medicines stored as the assessment says, such as in a lockable drawer in their room, and a record of what was supplied to them
   • Ask staff what they do after an error, a refusal or a reaction — who they tell, how they record it, how they get advice in and out of hours, and that a suspected adverse effect is reported to the prescriber
6. 6
   Phase 6

   Phase 6: Controlled Drugs

   7 tasks

   This phase applies when the service holds controlled drugs; answer No on the first task to hide it. Count every controlled drug against its register balance. A balance that does not match adds a task to investigate and report it.

   • Check controlled drugs are stored in a CD cabinet — controlled drugs that need safe custody kept in a cabinet that meets the Misuse of Drugs (Safe Custody) Regulations 1973, nothing else stored in it, access limited to staff who need it, and spare keys secure
   • Check the controlled drugs register — a bound register with numbered pages or a compliant electronic register, a separate page for each medicine, strength and form, entries made on the day in date order, and corrections made in the margin with the date, never crossed out
   • Count each controlled drug against its register balance — every running balance counted, with a second member of staff where your policy asks for one, and the count recorded with the date and signatures
   • Investigate and report the controlled drugs discrepancy — shown when a balance did not match: trace the register and records back to the last correct balance, report it to the controlled drugs accountable officer and, where the policy says so, the police, and record what was found
   • Check controlled drug doses are signed and witnessed — each dose recorded in the register and on the MAR, signed by the member of staff who gave it and by a trained witness where your policy asks for one, with the site recorded for patches
   • Check controlled drug returns and destruction are recorded — unwanted and out-of-date controlled drugs kept apart from current stock, each return or destruction recorded in the register with a witness and the new balance, and destroyed only in the presence of an authorised witness where the law requires one
   • Check who controlled drug concerns are reported to — the policy names the controlled drugs accountable officer for the service, with current contact details for them, the police and anyone else to tell about a discrepancy, loss or theft
7. 7
   Phase 7

   Phase 7: Disposal, Transfers & Incidents

   5 tasks

   Medicines errors often happen when people move between care settings. Check a sample of recent admissions and transfers, then review every medicines incident and near miss since the last audit.

   • Check medicines for disposal are stored and recorded — unwanted and expired medicines, including those of anyone who has died, kept in a tamper-proof container within a cupboard, recorded, and returned or collected promptly
   • Check medicines were reconciled for recent admissions — for each person admitted or back from hospital since the last audit, a current list checked against what they arrived with and their discharge information, any differences resolved with the prescriber or pharmacist, and the MAR updated, with the date and who did it
   • Check medicines information goes with people who leave — for a transfer, complete information about their medicines shared with the new service, ideally within 24 hours, and for a short absence, their medicines with clear directions and the times of the last and next doses
   • Review medicines errors and near misses since the last audit — each one recorded, including near misses and errors that caused no harm, its root cause found, action taken, and the learning shared with staff
   • Check medicines incidents were reported to the right people — safeguarding concerns through local safeguarding processes, notifiable incidents to the regulator, controlled drug incidents to the accountable officer, and the person or their family told what happened
8. 8
   Phase 8

   Phase 8: Findings, Action Plan & Sign-off

   7 tasks

   Rate each section the same way every time, so this audit can be compared with the last. Any item rated Not met adds Phase 9. The manager signs off the report and action plan, and nothing after the sign-off can be completed until they do.

   • Escalate anything unsafe before you leave — tell the person in charge about any risk to someone’s safety, such as a missed critical dose or an unexplained controlled drug loss, and record what was done on the day
   • Rate each section and the overall result — each section from Phase 2 to Phase 7 rated by its items met, partly met and not met, leaving out items not observed; any item rated not met adds Phase 9
   • Write the action plan with owners and dates — one action for each item partly met or not met, with who will do it and by when, the most serious first
   • Write the audit report — what was audited and sampled, what was done well, the ratings, the actions, and anything that could not be checked and why
   • Manager signs off the audit report and action plan — Approved, Approved with conditions or Not approved, with any conditions or reasons recorded
   • Feed back the results to staff and governance — what went well, what must change and who owns each action, shared with the team, the pharmacist and the governance or medicines safety meeting
   • Set the date of the next audit — on the cycle your policy sets, sooner after a poor result, with open actions carried into it
9. 9
   Phase 9

   Phase 9: Actions & Follow-up Check

   3 tasks

   Shown only when an item was rated Not met. Each action is put right by its owner, then the items that fell short are checked again.

   • Put right each item rated not met — each action done by its owner and evidenced, including retraining or reassessing staff where practice fell short
   • Re-check the items rated not met — the same items checked again with the same method, each recorded as now met or still not met
   • Manager closes the action plan — or sets a further check date if an item is still not met