SIL Audit Checklist — Medication Checklist (Tasmania Standards)

Policies and Procedures and forms

	Compliant	Non-Compliant	Comments
Is there a medication policy and procedure that is in-date and implemented?
Do the policies and procedures outline practices specific to the organisation’s sites, service delivery, and staffing arrangements?
Are procedures in place for collecting data about and reviewing all medication errors, incidents, near misses and adverse medication events? do records reflect this
Do policies and procedures identify when the NDIA commission must be notified as the result of a medication incident
Is there an Individual Support/Health Management Plan for each participant that includes: - Consent? - Individual preferences regarding medication management and administration? - Assessments and arrangements for self-administration? - Strategies to increase participant capacity for self-administration? - clear instructions about the physical assistance and supervisory role the DSW will take in the administration of medications if required
Is there clear information for employees on whom to contact for support during unexpected medication events or for clarification on medication?
Has an assessments been completed for capacity to self-administer?
Are strategies to increase participant capacity for self-administration documented?
Is there clear information for employees on whom to contact for support during unexpected events or for clarification?
Is there procedures for verifying that non-prescription medications are approved by a relevant health professional before use with other prescription medications.

Training and Competency

	Compliant	Non-Compliant	Comments
Do all support workers meet the required competency level to provide safe support in medication administration?
Has the provider ensured training is provided by a Registered Training Organisation (RTO) following AQF standards, including units: - Have staff been trained in first aid - HLTAAP001 Recognize healthy body systems; and - HLTHPS006 Assist clients with medication, OR - HLTAID003 Provide first aid and the CHCSS00070 Assist Clients with Medication Skillset?
Have staff been trained in first aid and CPR?
Do policies and procedures identify when the NDIA commission must be notified as the result of a medication incident
Have all staff completed a medication competency assessment?
Has the provider arranged additional training for complex medication administration if required for specific Health Management Plans? ( PEG, Epilepsy, asthma, diabetes, stoma, catheter) .
Is complex medication administration (overseen by a care plan developed by a qualified health professional?
Are workers’ knowledge and performance reviewed at least annually by a qualified person?
Is refresher training completed every 3 years as best practice?
Does the provider maintain a register of employee qualifications and current competency?
Is a reassessment of competency conducted in the following situations: - Following an incident or error linked to competency? - At the request of the DSW, participant, or family? - When requested by a supervisor due to performance issues? - When there is a change in health or medication needs? - When there is a change in environment or accommodation impacting task performance? - If the DSW has limited opportunity to apply previous training?
Does the provider ensure that recruitment, training, and scheduling of staff are aligned with medications management competency?
Are DSWs only assigned tasks that align with their knowledge, skills, experience, and training?

Supervision

	Compliant	Non-Compliant	Comments
Does the provider provide appropriate supervision to ensure DSWs perform medication duties competently?
Is supervision conducted in person or through communication methods (telephone, email, video conferencing) as needed?
Has the provider established supervision levels and frequency based on: - Task maturity of the DSW? - Need to review or assess participant condition and progress?

Disability Support Workers

	Compliant	Non-Compliant	Comments
Are DSWs only administering medications after being trained and deemed competent by the RTO?
Do DSWs understand and follow the Medication Management Framework, policies, and procedures?
Are DSWs administering medication according to health professional instructions and labeled directions?
Are DSW completing the 5 rights to medication administration and assessed as competent: 1. Right medication 2. Right person 3. Right dose 4. Right time, this includes the frequency and duration of the prescribed order 5. Right route and administration method as prescribed.
Are medical administration charts recorded in pen/ink documenting the administration of each medication?
Do DSWs understand and respect their own limitations and inform employers when they are not competent to perform medication administration tasks?
Before administering medication, do DSW understand and have access to the following info: • the reason an individual is taking each medication • how the medication is administered • possible side effects of the medication and interactions with other medications • be familiar with the location of all first aid equipment and how to use it • be familiar with first aid strategies and how to administer them.
Are DSWs refraining from administering Schedule 8 medications unless specified narcotics (dexamphetamine, methylphenidate, or lisdexamphetamine) or under Regulation 128 conditions?
Do DSW inspect any DAA medications upon collecting from a pharmacy?
Do DSW have access to medical charts or patient health summaries that document dose, time, frequency and maximum doses for PRN medication?
Is information about who to call in a medication event, or uncertainty easily available to DSW?
Is Medication checked at the end of a shfit? • medication documentation is completed • medication has been administered during the shift as prescribed • inform incoming staff of any changes to an individual’s medication • inform incoming staff of any individuals’ exhibiting effects or side effects of medication and any action taken or to be taken • note that medications have been checked and accounted for.
Is the following procedure followed when medication refusal occurs? • Explore with the individual why they are refusing to take the medication. • Explain to the individual why the medication is needed. • Wait up to 30 minutes and offer medication again. • If refusal persists call the prescribing health professional, dispensing pharmacist, or the Poisons Information Line (24 hours a day) on 131126 and follow their instructions. • Observe the individual for any changes in behaviour or wellbeing and report these to a supervisor. • Call an ambulance 000 if individual safety is at sufficient risk. • Record refusal of medication with a code R on the Medication Administration Record. • Notify the prescribing medical professional as soon as possible after the refusal about the incident and seek advice regarding future treatment • Notify other staff or staff working subsequent shifts.

Medication Administration

	Compliant	Non-Compliant	Comments
If a non-prescription medication is required, is the following documentation obtained before administering? Indications for use Generic name Administration route Dosing frequency Side effects and desired effects Maximum dosage and duration Confirm non-prescription medications are reviewed by a medical practitioner if used regularly.
Are all Complementary and Alternative Medications (CAMs) approved by a treating health professional?
Verify that no medication is administered if removed from its original packaging or SDAA to avoid errors.
is all SDAA is repackaged by a pharmacist when there are changes to medications.
Confirm DSWs only administer Schedule 4 medicinal cannabis prescribed legally and dispensed by a pharmacist.
Ensure all medications are stored in their original or appropriate pharmacy packaging or SDAA.
Confirm PRN medication instructions are provided by the prescriber, including maximum daily dose.
Verify that a three-day supply of all medications is maintained to prevent disruptions.
Ensure stockpiling is avoided to reduce waste, and expiration dates are regularly checked.
Is family administration of medication noted with the code "F" in the MAR when relevant?
Confirm consultation with a pharmacist before altering the form of any medication (e.g., crushing tablets).

Storage & Disposal of Medications

	Compliant	Non-Compliant	Comments
Medications stored and transported according to manufacturer’s recommendations (e.g., refrigerated if required).
Medications stored in original containers or pharmacy-issued SDAA.
Medications stored in a locked cupboard or room.
Medications stored separately from antiseptics, disinfectants, and other chemicals.
Keys to medication cabinet are clearly labeled and held by the designated person in charge.
Spare set of keys stored securely on-site.
Refrigerated medications stored in a key-locked container, separated from food items.
Medications under control of the individual (if self-managing) or a designated staff member at all times.
End of shift checks completed for MARs and Register of S8/S4D medications.

Storage of S8 and S4D Medications

	Compliant	Non-Compliant	Comments
S8 and S4D medications stored in a locked safe or secure enclosure, separate from other medications.
Enclosure for S8/S4D medications meets security requirements based on quantity stored.
Key to S8/S4D enclosure accessible only to authorised personnel.
Disposal of Medications and Packaging
Outdated or unused medications returned to pharmacy for disposal.
Personal information on empty medication packaging removed or obscured.
Record kept of medications disposed, including date and method of disposal.

Safe Sharps Disposal

	Compliant	Non-Compliant	Comments
Sharps disposed of in a suitable container with rigid, puncture-resistant walls.
Sharps disposal containers securely closed and sealed before disposal.
Sharps disposed at a designated collection facility or sharps disposal bin.
Sharps kept out of reach of children and others who may be harmed.

Medication Records Keeping

	Compliant	Non-Compliant	Comments
Current Medication List maintained for each individual.
List includes prescription, non-prescription, and CAM medications.
Medication lists includes: - individual’s name, address, and date of birth. Emergency contact details: GP/prescriber name, address, and phone number. - Medication details: brand name, active ingredient, strength, form, dose, frequency, route, start date, and end date. - Indication of what each medication is being taken for. - Known allergies or adverse reactions listed.
Date of the most recent medication review noted.
Medication List accessible to the individual and anyone involved in their care.
Consent obtained from individual or responsible person for sharing Medication List information.
Procedures reflect that medication lists are updated promptly with medication changes.
Medication Lists are reviewed after hospital visits or healthcare appointments to reflect any changes.
MAR maintained for individuals not managing their own medications, including prescription, non-prescription, and CAM meds.
MAR for self-managing individuals provided with template and coded (e.g., “F” for family-administered doses).
MAR meets all standard requirements outlined in Appendix 1.
Hard copy Medication register kept, bound with serially numbered pages.
Corrections made by crossing out errors and initialing; no “white-out” or pencil used.
Each S8/S4D medication has its own dedicated page.
Record of medication receipt entered at time of receipt.
Record of medication administration entered immediately upon administration.
Register entries signed by individual administering or placing medication into enclosure.
Where possible, two persons involved in S8/S4D medication entries.
Register balance checked and signed off by both parties during shift handover.
Discrepancies reported immediately to a supervisor and documented.
an incident report with Remedial actions are recorded if a medication error occurs.
Tasmania Police contacted if potential criminal activity is identified.
A nominated responsible person reviews MAR to ensure no missed doses and an accurate record is maintained.
Responsible person checks S8 and S4D Register balance to reconcile with MAR at the end of each shift.

* Appendix 1

Sections for including the individual’s identification details – a complete name, date of birth

• Space for alerts, i.e., individuals with similar names
• Section that allows for signing for administration, including those medications not packed in SDAAs
• Section for allergies and previous adverse reactions.
• Section indicating that a comprehensive medication review has occurred and by whom e.g., GP or
pharmacist
• Section for PRN medications
• Section for once only / STAT doses
• Section for emergency medications
• Section for nurse or DSW initiated non-prescription medications (See section 4.4 for guidance)
• Section for individual initiated medication or complementary medications
• Indication whether medication needs alteration of dose form
• Indication if the medication is considered High Risk
• Allows staff to enter the date of infrequently administered medications
• Area to include a recent photo
• A section for including contact details for the individual’s GP and pharmacy
• Immunisation information
• The MAR should be signed by the prescriber.

Medication in the community or away from home

	Compliant	Non-Compliant	Comments
Length of time individual will be away from home assessed and sufficient medication supply is prepared by pharmacist
Identify who will transport and store medications.
Medication for time away is kept in original pharmacy packaging or SDAA, this may require separate packaging.
List of prescribed medications and MARs are kept with medication and completed by DSW ( if supported) while off-site recorded.
Medications stored per manufacturer’s instructions, e.g., refrigerated meds in an insulated box for short transport.
Medication is kept securely during transport or in public i.e. locked container

Admission/discharge to hospital requirements

	Compliant	Non-Compliant	Comments
A transition document is completed and provided to the hospital with the following: - complete list of all medications, including prescription, non-prescription, and CAMs, upon hospital admission. - conditions treated by each medication and any specific instructions - allergy history and any past adverse reactions - copy of MAR, Medication List, Health Management Plan, and any other relevant documents are provided.
A discharge checklist is in place to ensure the following - discharge medications are listed with administration instructions, including dose, timing, route, and method. - who will oversee monitoring and review post-discharge (e.g., individual’s GP). - Provide instructions on resuming any pre-admission medications. - Verify any prescribed supply upon discharge and follow up with GP if ongoing supply is needed. - Return all Patient's Own Medications at discharge or offer disposal option if not needed. - Confirm up-to-date SDAA preparation through coordination between hospital and community pharmacy. - Confirm discharge summary sent to individual’s GP within 48 hours.

Storage & Disposal of Medications

	Compliant	Non-Compliant	Comments
Medications stored and transported according to manufacturer’s recommendations (e.g., refrigerated if required).
Medications stored in original containers or pharmacy-issued SDAA.
Medications stored in a locked cupboard or room.
Medications stored separately from antiseptics, disinfectants, and other chemicals.
Keys to medication cabinet are clearly labeled and held by the designated person in charge.
Spare set of keys stored securely on-site.
Refrigerated medications stored in a key-locked container, separated from food items.
Medications under control of the individual (if self-managing) or a designated staff member at all times.
End of shift checks completed for MARs and Register of S8/S4D medications.

Storage of S8 and S4D Medications

	Compliant	Non-Compliant	Comments
S8 and S4D medications stored in a locked safe or secure enclosure, separate from other medications.
Enclosure for S8/S4D medications meets security requirements based on quantity stored.
Key to S8/S4D enclosure accessible only to authorised personnel.
Disposal of Medications and Packaging
Outdated or unused medications returned to pharmacy for disposal.
Personal information on empty medication packaging removed or obscured.
Record kept of medications disposed, including date and method of disposal.

Safe Sharps Disposal

	Compliant	Non-Compliant	Comments
Sharps disposed of in a suitable container with rigid, puncture-resistant walls.
Sharps disposal containers securely closed and sealed before disposal.
Sharps disposed at a designated collection facility or sharps disposal bin.
Disposal of Medications and Packaging
Sharps kept out of reach of children and others who may be harmed.

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Meditation Checklist — Tasmania Standards