Clinical Audit Assignment

Clinical Audit Assignment.
Introduction.
There are many benefits in carrying out a clinical audit. It allows nurses to evaluate the care they are giving, encourages them to keep better records, focuses on the care given rather than the care giver themselves and achieves a feasible quality of nursing care (Harmer and Collinson 2005).
According to Clement (2012), a nursing audit can be defined as a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. There are different types of nursing audits to choose from. A nursing management audit, which is a structured audit that concentrates on the administrative aspect of nurses responsibilities. A retrospective audit which

Drug Kardexes were gathered and audited under certain criteria in order to identify potential risk areas in drug prescribing and administration, and also to provide ways in which these risks can be reduced or eliminated and reinforce drug management policies’ and guidelines. NICE (2002) audit cycle will be applied to this assignment to provide an acceptable framework (Appendix 1).
Step 1: Preparing for Audit.
The first step in the audit process is to identify which type of audit is to be carried out. In this case the concurrent review was chosen. As discussed previously in the assignment it was decided that drug kardex documentation would be audited. A drug kardex, also known as drug prescription or drug script is defined by the World Health Organisation (2002) as ‘’an instruction from the prescriber to the dispenser’’. In this instance the prescriber will be identified as any doctor in the hospital setting with prescriptive authority and the dispenser can be identified as any registered general nurse.
For this Audit the author took the following steps in developing questions for the Audit tool as guided by The National Institute for Clinical Excellence

In order to correctly identify the right patient this addressograph should contain the patients name, address, date of birth and unique identity umber. On administration of medication these details should be cross checked between the patients’ armband and their drug kardex. These details should also be checked with the patient on admission to ensure that they are correct. To further protect the patient, their allergy status should be clarified and documented on the kardex. If the patient is unable to verify this for themselves a family member, carer or General Practitioner may be able to provide this information. This should also be asked to the patient on every drug round as new drugs can be described at any time. The patients’ weight should be recorded on the kardex also as certain drugs are given according to weight such as Infliximab and their weight will determine the required