Polices and Regulations to Audit

Adharsh Murali

Department of Health Information Management, Texas State University

Dr. Jennifer Teal

April 6, 2024
 Polices and Regulations to Audit

One vital policy to audit in a hospital setting is the Medication Management Policy. This

policy is crucial because it directly impacts patient safety and the quality of care provided by the

organization. The Medication Management Policy generally covers roles and responsibilities,

prescription writing, medication ordering and dispensing, documentation, error reporting and

management, medication administration, monitoring of medication effects, and patient

education.

An audit of medication management policy would involve inspecting the procedures at

the healthcare facility and examining compliance with these procedures. Internal audits of

medication administration policies at a hospital are crucial for ensuring patient safety and

compliance with regulatory standards.

Medication Errors

The audit must include reviewing medication errors to identify any trends or systemic

issues the facility needs to address to rectify and provide quality patient care. The audit's goal is

to ensure that the Medication Management Policy effectively promotes the safe and effective use

of medications and identifies improvement areas.

Policy Adherence and Regulatory Compliance

The audit should assess whether the medication administration policy is followed

consistently, which includes, checking that all steps of the medication administration process are

followed, such as verifying patient identity, checking medication orders, and documenting

administration. The audit should assess whether the hospital complies with relevant regulations
and standards related to medication administration, which involve reviewing policies,

procedures, and practices against regulatory requirements.

Staff Training and Competency

Staff training and competency are the most critical because the appropriate training and

competencies will reduce medical errors and missing documentation. The auditing panel should

review the training records, including observing the staff while administering medication.

Patient Education

The competency training involves staff and patients for the betterment of the patients.

The audit must evaluate the procedures for educating patients about their medications. This

includes checking the completeness and accuracy of patient information and the methods used to

confirm patient understanding.

Medication Storage and Disposal

The audit should assess whether medications are being stored and disposed of correctly.

This includes checking that medications are stored securely and at the correct temperature and

that expired or unused medications are disposed of safely and appropriately.

Prescription Writing

The audit must inspect the facility's prescription writing standards by checking

prescriptions' legibility, completeness, and accuracy and ensuring that they include all necessary

information, such as patient name, medication name, dosage, frequency, and route of

administration.
Quality Policy and Procedure Improvement

The audit should evaluate whether the hospital effectively uses quality improvement

strategies to enhance medication administration. This could involve reviewing audit results,

feedback from the previous auditing, and improvement initiatives.

Concurrent Audit

The choice between a concurrent and retrospective audit depends on the specific goals

and circumstances of the healthcare facility's audit. However, a concurrent audit might be more

beneficial in the context of a hospital's Medication Management Policy audit.

The most comprehensive and effective audit conducted at the facility is a concurrent

audit for the medication management policy audit because it is executed in real-time. At the

same time, the activities are ongoing, allowing auditors to observe processes, identify issues

immediately, and provide timely feedback, which will help the staff improve. Medication

management could imply observing the prescription, dispensing, administering, and monitoring

of medications as they occur. Observing in real time helps identify and address issues that could

immediately impact patient safety.

In the context of a Medication Management Policy audit, a comprehensive audit would

be more appropriate because a comprehensive audit involves thoroughly examining all relevant

data and procedures. Therefore, the auditing panel must inspect all the processes and procedures

for prescribing medication to patients. However, this approach is more time-consuming and

resource-intensive, but it provides a complete illustration of the hospital's medication

management practices.

The auditing panel includes a Clinical pharmacist, Registered Nurse, Physician, Quality

Assurance Specialist, Health Information Manager, and Legal advisor.

Clinical Pharmacist

A clinical pharmacist is an expert in medication management, dispensing, and

monitoring. They can provide valuable insights into the appropriateness of medication use and

related issues.

Registered Nurse

Nurses are responsible for administering and monitoring patient medication, and they can

speak about its practical aspects.

Physician

A physician can provide a medical perspective on medication use, including the

appropriateness of the chosen medications and doses and the management of any adverse and

side effects.

Quality Assurance Specialist

A quality assurance specialist can provide expertise in audit procedures and standards and

help ensure the audit is conducted rigorously, systematically, and with compliance.

Health Information Manager

A health information manager is an expert in managing and analyzing health data and

procedures. So, they can provide valuable support in reviewing the patient's medication records

and identifying patterns or trends.

Legal Advisor

Given the potential legal implications of medication errors, including a legal advisor on

the audit team may be beneficial. The executive summary

The Medication Management Policy audit report should include several key components,

including an executive summary, procedures, findings, and recommendations. Their findings and
recommendations must include complete auditing reports, what policies are working well for the

facility, what policies can be changed, and what training can be given to staff and other

members. The report should be presented to key stakeholders, such as the hospital

administration, medical director, pharmacy director, IT Director, and Quality assurance

committee.

Internal auditing and reporting are beneficial to the healthcare facility because the

organization's members conduct them. Also, internal auditing of the medication management

policy will give them quick identification of problems, and the hospital has a chance to improve

it based on recommendations. This will result in faster resolutions to hospital issues.

Internal reporting can support better decision-making at all organizational levels by providing

timely and relevant information. Regular internal auditing will also promote employee

accountability and compliance, enhancing their performance. Internal auditing and reporting can

also help the organization identify potential risks, and planning to manage those risks will protect

the organization. In a medication management policy audit, internal reporting would allow for

the immediate identification and resolution of medication management issues, enhancing patient

safety and care quality and improving the healthcare facility.