Medication Safety Audit Tool

Medication errors and medication-management breakdowns are among the most common drivers of avoidable harm in healthcare litigation. This tool helps attorneys audit prescribing, dispensing, administration, monitoring, and documentation to identify deviation points that support breach, causation, and credibility analysis.

Use this tool during case screening, timeline reconstruction, expert preparation, mediation, and deposition strategy in any setting (hospital, LTC, home health, hospice, ALF).

1. Medication History & Reconciliation

Confirm the Baseline Medication Profile

• Home medication list obtained and documented
• Allergies and reactions clearly documented
• High-risk meds identified (anticoagulants, insulin, opioids, sedatives, antipsychotics)
• Renal/hepatic considerations documented where relevant
• Medication reconciliation completed at admission and at transitions of care

Red Flags

• No medication reconciliation
• Conflicting medication lists across records
• Allergies missing or inconsistently documented
• High-risk meds continued without risk assessment
• Medication list not updated after transfer, discharge, or change in setting

2. Prescribing & Order Quality

Audit the Medication Orders

• Indication documented for each medication
• Correct dose, route, and frequency
• Appropriate PRN parameters (when-to-give, max dose, reassessment requirements)
• Hold parameters for meds impacted by vitals/labs (BP, HR, glucose, INR, renal function)
• Duplicate therapy avoided (same class meds without rationale)
• Drug-drug interaction risks considered and documented

Red Flags

• Orders missing dose/route/frequency
• No PRN parameters or reassessment requirements
• High-risk meds ordered without monitoring plan
• Contraindicated meds given despite allergies or interactions
• Conflicting orders or unclear discontinuation

3. Dispensing, Verification & Pharmacy Communication

Confirm Safety Controls

• Pharmacy verification completed prior to administration (where applicable)
• Medication availability delays identified
• Clarification calls documented for unclear orders
• Substitutions / formulary changes documented
• Medication delivery timing aligns with clinical need

Red Flags

• Medication not available / delayed without escalation
• Order clarification not documented
• Substitution made without provider approval
• High-alert meds dispensed without verification safeguards

4. Administration Audit (MAR Integrity)

Evaluate Administration Accuracy

• Right patient / medication / dose / route / time documented
• Missed doses clearly documented with reason
• Late doses documented with reason
• Refusals documented with follow-up and provider notification where required
• PRN administration linked to documented symptoms and reassessment
• Controlled substances counted and reconciled per policy

Red Flags

• Missing MAR entries or unexplained gaps
• Late or missed doses without documentation
• PRNs given without symptom documentation
• No reassessment after opioid/sedative/antipsychotic PRNs
• Controlled substance discrepancies

5. Monitoring, Side Effects & Clinical Response

Confirm Required Monitoring Occurred

• Vitals/labs monitored as required for the medication profile
• Monitoring documented after initiation, dose changes, or high-risk meds
• Adverse effects identified and documented (sedation, hypotension, hypoglycemia, bleeding, delirium)
• Provider notified when parameters exceeded thresholds
• Medication held or adjusted appropriately based on clinical status

Red Flags

• No monitoring plan for high-risk meds
• Abnormal vitals/labs not escalated
• Side effects documented without intervention
• Delayed provider notification after adverse response
• Medication continued despite documented harm indicators

6. Transitions of Care (Transfer / Discharge / Setting Change)

Audit the Handoff Medication Story

• Medication reconciliation completed at transfer/discharge
• Medication changes clearly documented with rationale
• Discontinued meds clearly marked and communicated
• Receiving facility/home instructions consistent with the active med list
• High-risk meds include monitoring/precautions in the handoff

Red Flags

• Conflicting med lists between settings
• Discontinued meds still administered
• New meds started without indication
• No instructions for monitoring high-risk meds
• Handoff missing medication changes

Global Medication Red Flags

• Missing or contradictory medication lists
• No medication reconciliation at admission or transfer
• Missed or late doses without explanation
• PRNs administered without indication or reassessment
• High-risk meds without monitoring plan
• Abnormal vitals/labs ignored (e.g., BP, glucose, INR, creatinine)
• Failure to document provider notification after adverse effect
• Controlled substance discrepancies
• Late entries or inconsistent MAR documentation
• Medication changes with no follow-up assessment

These patterns frequently correlate with breach, causation leverage, and credibility risk across all healthcare settings.

Medication Safety Audits Expose High-Risk Deviations and Preventable Harm

Many cases turn on whether medication decisions were clinically appropriate, properly communicated, accurately administered, and adequately monitored. The Medication Safety Audit Tool evaluates prescribing rationale, MAR integrity, monitoring, and escalation response to identify breach points, alternative causation issues, and documentation vulnerabilities that shape liability exposure and case strategy.

Submit Records for Medication Safety Audit

HIPAA-secure intake • MAR integrity & monitoring review • Standard 7-day delivery