Roy Mariathas and Joanna Chanmugam

UWS Medical Students – April 2010

Chesalon Care Services

Project Report: Clinical Audit – Medication Management
Chesalon Care Services provide residential care for frail aged people who require high level care.
They offer permanent and respite accommodation at six different centres in New South Wales
[1]. More commonly, this type of facility would be considered as a ‘Nursing Home’. However this
label and stereotypes that come with it do not adequately describe the services provided.

After spending time at Chesalon Care Richmond, it was evident that high quality care was
delivered to provide for the residents holistically. Their philosophy involves a Christian centred
approach, taking into account of the interdependence of their physical, emotional, spiritual and
social needs to provide for their total well being [2]. This is achieved while maintaining
independence and dignity of the residents.

Chesalon offers hotel services including administration, maintenance of buildings and grounds,
accommodation, furnishings, bedding, cleaning services goods and facilities, waste disposal,
general laundry, toiletry goods, meals and refreshments, social activities for residents and
emergency assistance. To those residents who require care higher than the needs of hotel
services, the following is also offered: assistance of activities of daily living, emotional support,
treatments or procedures, recreational therapy, rehabilitation therapy and access to health
practitioner and specialised therapy services and support for residents with cognitive
impairment. Furthermore, residents with the highest needs are provided with goods to assist
residents to move themselves (and with staff assistance), toileting and incontinence
management, basic medical and pharmaceutical supplies and equipment, nursing services,
medications and Oxygen therapy [3].

The project for this placement involved conducting an internal audit on the Management of
Medication at Chesalon Richmond. Fowkes [4] describes an audit as a “comparison of an actual
practice to a standard of practice and as a result of the comparison, any deficiencies in actual
practice may be identified and change undertaken to rectify the deficiencies.” A clinical audit
serves a more specific purpose, and has been described as “The systematic, critical analysis of
the quality of medical or clinical care, including the procedures used for diagnosis and
treatment, the use of resources, and the resulting outcome and quality of life for the patient”
[5].

Chambers et al [6] conducted a study investigating the effects of introducing an audit project
into Nursing Homes in the United Kingdom. Notable improvements in the standard of care were
associated with the introduction of audits. A fall in the average Geriatric Depression Score in
some of these homes was noted after the audit was conducted.

The use of medications can significantly impact an individual and greatly improve their quality of
life. However, incorrect use of medications may be detrimental to one’s health. Close to all
residents at Chesalon use medication on a daily basis, therefore it is vital that the appropriate
medication is prescribed, dispensed, administered and nurses are provided with necessary
information regarding these medications [7]. A Medication Management Audit is designed to
make certain that this system is managed safely and accurately.
 Roy Mariathas and Joanna Chanmugam
UWS Medical Students – April 2010

Chesalon Care has devised its own Clinical Auditing Program which the Medication Management
Audit is part of. The references and guidelines for this audit were taken from the Department of
Health and Ageing [8] and the Australian Pharmaceutical Advisory Council [9].

The Clinical Audit has a number of guidelines that need to be met in order for standards to be
maintained. These include the following [7]:
1. Residents have a current correctly completed medication chart which includes:
2. Medication reviews are carried out regularly by the resident’s medical practitioner
3. The facility has a process in place for regular independent reviews of the medication
management system. Eg: pharmacist or Meditrax
4. The facility has a regular Medication Advisory Committee meeting to review processes.
5. There is a regular education available for staff on medications and processes.
6. There is a process in place for identifying and recording medication errors.
7. There is process in place for the ordering of resident’s medications both in normal and
extraordinary circumstances.
8. There is a process in place for the management of dangerous drugs (S8 and S4).

The above criteria were assessed using a number of methods. 10% of resident’s medication
charts were reviewed and compared to details recorded on their Profile on iCare, a system of
computerised health records. These residents were selected randomly so as to eliminate any
bias that may occur between residents living in the same ward. Resident details on the
medication charts including name, date of birth, date of admission, Medicare number and
pension number were all verified. Medication charts were also required to display resident’s
allergies and adverse drug reactions of the drugs. The dose, frequency and route of each drug
had been correctly noted on the charts. Any orders had been signed and dated.

The medication charts also displayed the date for the last medication review. In the 10% of
medication charts reviewed, it was noted that the last review had occurred recently, in the past
12 months. The most recent review on Nurse Initiated Medications was also recorded.

Meditrax provides “professional medication management and monitoring services for

residential aged care facilities” [10]. They perform reviews on the Medication management at
Chesalon by obtaining a small number of residents as a sample population. Their last three
reviews were identified and it was noted if the frequency of such reviews was adequate. The
Medication Advisory Committee’s minutes over the past six months were not available.
However, the results over the past twelve months were sighted to determine if their actions
were up to date. A record of regular education on medications and associated processes
available for staff was also sighted for the previous 6-12 months.

Four nursing staff were then interviewed to assess their knowledge on what process would be
necessary to report errors and the availability of suitable forms in such circumstances. It was
found that incident report forms are available on iCare, and the appropriate staff are notified
when this occurs. These staff were also asked to describe the process for ordering medications
for residents in normal and extraordinary circumstances, such as an immediate need for
antibiotics. Normally, the doctor writes a script for any new medication or updates required for
each resident, noting the dose and time to be taken, and it is faxed through to the pharmacist.
Medication is then delivered later that afternoon or the next day. Staff were able to answer
these questions competently. In extraordinary circumstances, Chesalon usually has antibiotics
available on site. The process for managing and storing dangerous drugs was also covered by
 Roy Mariathas and Joanna Chanmugam
UWS Medical Students – April 2010

staff. It was established that Schedule 4 drugs were stored in a single lock cupboard, while
Schedule 8 drugs were stored in a double lock cupboard. Only the Registered Nurse on each
ward had the key to these drug cupboards. S8 drugs were counted before and after
administration each day, and the number of tablets were recorded. It was noted that two staff
must always be present upon obtaining these drugs from the cupboard.

In a study published in August 1000, findings concluded that nearly half of the adverse drug
events occurring in 18 nursing homes were preventable. [11] If so, then room for improvement
on preventing such errors is clearly shown. There is an obvious need for constantly monitoring
and improving a health care system let alone medication management. The interdependence
and multi-faceted character of health care translates to one change in the system to affect many
aspects. Changes made open liability for its components to be affected. For example, if an
employment change is made to those dispensing medications, then the way medications are
managed is subject to change and therefore error. Thus periodic review and updating is of good
practice. In particular, medications of patients and pharmaceuticals available on the market are
constantly changing and between the various generic and brand names available added to the
common polypharmacy of geriatrics allows for a myriad of error.

The clinical audit becomes effective in this area of monitoring, updating and improvement. It
allows for health care to continue to be beneficially multi-faceted, interdependent and changing
while “picking up the pieces” so as to speak and correcting the system. One might question the
effectiveness of such “negative” commentary on a system, where even mentioning the word
“audit” brings about negative connotations generally speaking and did so during information
gathering with staff. However this can be easily addressed via positive feedback combined with
productive criticism to bring about forward change.

Clinical audits are able to bring about positive change in a health care system but need a realistic
timeframe, necessary resources as well as a tolerant culture of learning in organisations.
Furthermore the success of clinical audit depends on the commitment and support of the
management of the organisations as stated. [12]

The outcomes and subsequent actions proposed of the clinical audit conducted in relation to
medication management at Chesalon Care, Richmond are as follows: [7]

Outcome Action
Adverse drug reactions not stated across the Validate iCare patient and Medicare details
board; minor errors in Medicare and pension and refer to next Medication Advisory
details Committee (MAC) meeting
Nursing-initiated medications (NIMs) have not MAC to review NIM listing
been revised since 2007
Management systems audit irregular (most Refer to manager for independent clinical
recent July ’09, then August ’08) auditing
Education not conducted within the past six Refer to manager for organisation of education
months on medication management

In conclusion, the aim of clinical auditing is the continuous improvement of health care quality
from the systematic and critical analysis of current practice against predetermined criteria and
change made if necessary. In this case, areas of system improvement were identified and passed
on to management for implementation.
 Roy Mariathas and Joanna Chanmugam
UWS Medical Students – April 2010

References

1. Anglicare. Chesalon Living. [Online]. 2010. [cited 2010 April 1]. Available from URL:
http://www.anglicare.org.au/our-services/chesalon-living/

2. Anglicare: Chesalon Living. Philosophy of Care for Frail Aged Persons. 2002.

3. Anglicare: Chesalon Living. Information for Residents and Relatives of Chesalon Care. Care and Services.
January 2009.

4. Fowkes FRG. Medical audit cycle. A review of methods and research in clinical practice. Med Educ. 1982;
16:228-238.

5. Secretaries of State for Health, Wales, Northern Ireland and Scotland: Working for patients, London, HMSO,
1989. Working Paper 6: Medical audit.

6. Chambers R, Knight F, Campbell I. A Pilot Study of the Introduction of Audit into Nursing Homes. Age and
Ageing. 1996; 25:465-469.

7. Chesalon Care. Clinical Auditing Program; Audit Topic: Medication Management. Sydney, Australia.
Anglicare. 2007.

8. Aged Care Division of the Department of Health and Ageing. Standards and guidelines for residential aged
care services manual. [Online]. 1998. [cited 2010 April 5]; Available from URL:
http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-manuals-sgr-sgrindex.htm~ageing-
manuals-sgr-sgrindex-2.htm

9. Guidelines for medication management in residential aged care facilities. Australian Pharmaceutical
Advisory Council. November 2002. 3rd Edition.

10. Meditrax. [Homepage on the internet]. Annandale, Australia. [Online]. 2008. [cited 2010 April 6]. Available
from URL:http://www.meditrax.com.au/

11. Jeannine Mjoseth. Adverse Drug Events in Nursing Homes: Common and Preventable. [Online]. 2000. [cited
2010 April 5]; Available from URL:
http://www.nia.nih.gov/NewsAndEvents/PressReleases/PR20000809Adverse.htm

12. Mogyorósy G, Mogyorósy Z. The role of clinical audit in the quality improvement of health care. Orv Hetil.
2004. 145(43):2191-8.