Evaluating Healthcare Documentation and Safety Standards

The provided assignment focuses on evaluating healthcare documentation and safety standards, specifically examining medication management practices, clinical documentation guidelines, and patient safety protocols. It draws from various research articles and studies, including works on medication administration errors, medication sharing and disposal, and the importance of accurate documentation in ensuring patient safety and quality care. The assignment requires analysis and evaluation of these concepts, highlighting their significance in healthcare settings and the potential consequences of inadequate documentation or medication management.

Running head: PHARMACOLOGY ASSIGNMENT
PHARMACOLOGY ASSIGNMENT
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Table of Contents
Introduction................................................................................................................................2
Medication errors.......................................................................................................................2
Ethical principles........................................................................................................................3
Legislation..................................................................................................................................5
Conclusion..................................................................................................................................6
References..................................................................................................................................7

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Introduction
Quality Use of Medicines (QUM) is part of the major objectives of
Australia’s National Medicines Policy. This refers to the selection of option so management
wisely. It also involves choosing of medicines only if it is necessary (Clark et al., 2014).
Medicines should be used safely and effectively. The main objective of the National Strategy
for QUM is to provide betterment of the health outcomes for all Australians and to make the
best possible use of medical facilities. This paper highlights the impact of medication error on
the health outcome of the patient. In addition to this, the paper illustrates the ethical
principles and legislative rules that should be complied with during nursing practise.
Medication errors
Poor nursing practices shown by the nurses had contributed to the poor health
outcome of patient Mr.L. while medication was being prescribed by Dr.K, the nurse A was
absent, whereas she should have been present on the scene. Additionally the nurse A failed to
check the medication char before leaving for break hence was not aware of the fact that new
medications had been added to the medication chart of the patient. While the patient was
handed over to nurse B, there was only a standard medication handover which consisted of
medications provided by Dr.K. after some time, only a brief verbal handover was attended by
Nurse B to the ward nurse, Nurse C. All these negligence summed up to the poor health
outcome of the patients’ health (Kim & Bates, 2013).
The nursing practise demands care to be provided to ensure appropriate
administration of medicines. All nurses have been trained with the “six rights of Nurses
Administering Medications”. These includes the “right to a complete and clearly written
order, the right to have the correct drug route and dose dispensed, “the right to have access to

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information, the right to have policies on medication administration”, “the right to administer
medications safely and to identify problems in the system” and “the right to stop, think, and
be vigilant when administering medications” (Melnyk et al., 2014). In this context the right
to have the access of information has not been maintained properly since the nurse had not
been updated about the addition of the new medications in the chart. The nurses before
administrating any drug should ask questions about the medicine, which was not observed.
The NSQHS Medication Safety Standard 4 item 4.6 states that the clinicians must
review the current medication orders of the patients. This should be conducted against any
past history of medication or the documented plan of treatment. The clinicians should
reconcile if any discrepancies are present on the transition and presentation of care (Adhikari
et al., 2014). In order to improve medication administration, steps should be taken like
matching of the medicine orders that are current with the BPMH. This should be done ideally
within 24 hours of admission. Suring transfer, the current list of medicine should be checked
and communicated while handover especially when medicines are recharted. After discharge,
the medicines that a5e ordered must be checked to make sure that they match with the
prescription present on the discharge plan along with medicine list. It should confirm the
changes that has been documented (Twigg, Duffield& Evans, 2013).
Ethical principles
The action that is done for the benefit of others is referred to as beneficence. Such
actions are taken in order to prevent harms and help to improve the situations of others. In
medical application, beneficence must be observed to refrain from causing of harm to the
patients. An ideal beneficence involves acts of generosity and benefiting others. The goal of
medicine as a whole is to promote the welfare of patients (Judkins-Cohn et al., 2014). This
involves possession of skills by the health personnel and knowledge that help them to assist

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others in needful situations. The relationship is such that physicians or nurseshave an
obligation to prevent harms and remove them along with weighing and balancing possible
benefits which needs to be taken. Beneficence also includes protection of the rights and
defending others along with rescuing individuals who are in difficulty. This might involve
patients with disabilities (Adhikari et al., 2014).
Non-maleficence means not to do harm. The individuals involved in healthcare must
avoid getting involved in ineffective treatment methods or practising malice towards the
patients. One of the consistent ethical issue is that whether the benefits are able to outweigh
the burdens (Judkins-Cohn et al., 2014). Care should be taken to ensure that the patients are
not put in any risky situation where there is no possibility of benefit. Therefore the patient
might have a chance of getting harmed. In addition to this, the healthcare personnel must
oversee that their action has significant benefit. Most of the medications, treatment
procedures and interventions might cause harm along with benefit, therefore he principle of
non-maleficence should be implemented so that it provides guidelines to the care of patients.
This particular principle is of greatest helpful when it is significantly balanced against the
principle of beneficence. Here in this study, non-maleficence points out that the treatment
risks needs to be understood in respect to the potentiality of benefits. Finally it is the decision
of the patient regarding the significant benefits, whether they are successful in outweighing
the potential harms or not.
There should be a balance between beneficence and non-maleficence ethical
principles. However there is always a rise of dilemma in balancing beneficence and non-
maleficence principles (Parahoo, 2014). This balance is the one that is present between the
risks of treatment and the benefits of treatment or taking a medical decision such as in case of
conduction of a particular test or operations or administration of medication. Provision of
informed consent enables the physicians to provide the information that is required to the

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patients. It helps the patients to make a decision regarding their treatment methods. Finally
the patient is responsible for assigning weight to the factors of risks and benefits. It is
required that he potential benefits of any intervention to outweigh the risks so that the action
is proved to be ethical.
Legislation
The drug legislation provides laws that are involved in checking the safety along with
the efficacy of veterinary drugs. The Veterinary Medicines Directorate (VMD) are involved
in these actions. They also check and inspect the manufacturing premises of the veterinary
drugs in addition to being stocked or supplied to the public (Barratt, Seear & Lancaster,
2017). It is necessary to enforce the regulations wherever necessary. It is required for the
nurses to be aware of these laws so that they are not involved in any malice towards the
patients. The laws provide proper guidelines for prior to administration of medication, along
with during administration and after administration of the medicines. The nurses through
these guidelines often receive proper training and education related to medicine
administration.
Therapeutic Goods Administration (TGA) is involved in regulation of medication at
the federal level. The TGA is involved in regulating the therapeutic goods by the process of
pre-market assessment (Parahoo, 2014). After this there is post-market monitoring. Standards
of enforcement along with licensing of the manufacturers is done by them. Additional roles
involves verification of the overseas manufacturers whether they comply with the countries
rules not. The organization possess obligations under the Protective Security Policy
Framework. This helps to the development and documentation that is implementedto measure
and to protect information from those who are unauthorised for use. They can also prevent
accidental modification or release and loss of information.

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Fentanyl was added to the list of schedule W drugs since its preparation contains
narcotic drugs. Irbesartan falls in the category of prescription, restricted, and pharmacy-only
medicine that is included in the schedule 1 of Medicines Regulations of 1984. Along with
fentanyl, oxycodone is also enlisted in the list of schedule W drugs (Kumari et al., 2016).
The nurse in charge is designated to be responsible to ensure that there is presence of
sufficient stocks and supplies in each wards and units for individual patients at all times. The
registered manager who are in charge of the unit is ultimately accountable for medicines held,
for each community team base. They ensure that Medicine policy procedures are followed
correctly. They also should ensure that the security of medicines is maintained. The
community staff needs to provide advice for safe storage of the medicines of the patients in
safe places. Preferably it should be in a dry atmosphere or in containers (Kennedy-Hendricks
et al., 2016).
Documentation is an important part of medical practise. Significant documentation
provides opportunity for development of diagnostic and therapeutic plan. Proper
documentation should be present in terms of the medications prescribed to the patient at
every stage. In case of any change of medications, there should be recharting of the
medications so that proper documentation should be present. In absence of documentation,
the rates of medication errors increase as there is no prove of the medicines that are
prescribed to the patient (McDonagh et al., 2014).
Conclusion
From the above discussion it can be concluded that the nurses should be careful with
the administration of medication to the patients. There are certain guidelines that the nurses
are needed to observe during their clinical practise in terms of medicine administration. The
paper also highlights the beneficence and the non-maleficent ethical principles that are

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observes along with the need to balance between the two practices. In terms of legislation, the
nurses should be aware of the drug legislations and the federal laws that govern the
medication use, to prevent mal practise against the patients.
References

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Adhikari, R., Tocher, J., Smith, P., Corcoran, J., & MacArthur, J. (2014). A multi-
disciplinary approach to medication safety and the implication for nursing education
and practice. Nurse education today, 34(2), 185-190. Retrieved from:
https://www.sciencedirect.com/science/article/pii/S0260691713003845
Barratt, M. J., Seear, K., & Lancaster, K. (2017). A critical examination of the definition of
‘psychoactive effect’in Australian drug legislation. International Journal of Drug Policy,
40, 16-25. Retrieved from:
Clark, A., Gilbert, A., Rao, D., & Kerr, L. (2014). ‘Excuse me, do any of you ladies speak
English?’Perspectives of refugee women living in South Australia: barriers to accessing
primary health care and achieving the Quality Use of Medicines. Australian Journal of
Primary Health, 20(1), 92-97. Retrieved from: http://www.publish.csiro.au/py/py11118
Judkins-Cohn, T. M., Kielwasser-Withrow, K., Owen, M., & Ward, J. (2014). Ethical principles
of informed consent: Exploring nurses’ dual role of care provider and researcher. The
Journal of Continuing Education in Nursing.Retrieved from:
https://www.healio.com/nursing/journals/jcen/2014-1-45-1
Kennedy-Hendricks, A., Gielen, A., McDonald, E., McGinty, E. E., Shields, W., & Barry, C. L.
(2016). Medication sharing, storage, and disposal practices for opioid medications among
US adults. JAMA internal medicine, 176(7), 1027-1029. Retrieved from:
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2527388
Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to
guidelines. Journal of Clinical Nursing, 22(3-4), 590-598. Retrieved
from:https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2012.04344.x
Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century:
executive summary of a policy position paper from the American College of

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Physicians. Annals of internal medicine, 162(4), 301-303. Retrieved from:
http://annals.org/aim/article-abstract/2089368
Kumari, B. S., Hanuja, G. S., Nagabhushanam, M. V., Reddy, D. N., & Bonthagarala, B. (2016).
Current Regulatory Requirements for Registration of Medicines, Compilation and
Submission of Dossier in Australian Therapeutic goods Administration. International
Journal of Advanced Scientific and Technical Research, ISSN, 2249-9954.Retrieved
from:https://rspublication.com/ijst/2016/dec16/15
McDonagh, J. E., Shaw, K. L., Stephenson, R., & Gray, N. J. (2014). Are they ready and do we
know they are ready? Documentation of medicine management tasks in an adolescent
rheumatology clinic. Rheumatology, 53(suppl_3), iii10-iii10. Retrieved
from:https://academic.oup.com/rheumatology/articleabstract/53/suppl_3/iii10/181424
Melnyk, B. M., Gallagher‐Ford, L., Long, L. E., & Fineout‐Overholt, E. (2014). The
establishment of evidence‐based practice competencies for practicing registered nurses
and advanced practice nurses in real‐world clinical settings: Proficiencies to improve
healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence‐
Based Nursing, 11(1), 5-15.Retrieved
from:https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/wvn.12021
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International
Higher Education. Retrieved from:https://books.google.
Twigg, D. E., Duffield, C., & Evans, G. (2013). The critical role of nurses to the successful
implementation of the National Safety and Quality Health Service Standards. Australian
Health Review, 37(4), 541-546. Retrieved from:http://www.publish.csiro.au/ah/ah12013

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