MEDICATION SAFETY AUDIT TOOL
A structured framework for identifying medication errors, compliance failures, and preventable harm across all healthcare settings.
Introduction to the Medication Safety Audit Tool
Medication errors are one of the leading causes of preventable injury and harm in healthcare settings, often resulting from systemic issues, inadequate communication, or failures in the medication administration process. For attorneys and healthcare professionals involved in litigation, accurately identifying and analyzing medication-related negligence is critical to building a strong case.
The Medication Safety Audit Tool is designed to assist legal teams in evaluating medication administration practices, identifying violations of standards of care, and uncovering systemic failures that may have contributed to patient harm. By systematically reviewing key areas such as medication reconciliation, administration records, timeliness compliance, lab monitoring, and provider communication, this tool helps pinpoint the critical vulnerabilities that could serve as breach indicators in medication-related negligence cases.
This audit tool serves multiple functions:
Case Screening: Identify early signs of medication-related errors that could indicate potential negligence or liability.
Breach Analysis: Evaluate specific areas of medication safety to determine whether deviations from established standards of care occurred.
Deposition Preparation: Structure your deposition strategy by identifying key areas for questioning medical staff, administrators, and healthcare providers.
Expert Review: Facilitate a detailed expert review by providing a comprehensive framework for assessing medication safety practices and uncovering contributing factors.
With this tool, legal teams can ensure that all relevant medication safety practices are thoroughly reviewed, and any potential gaps or failures are brought to light. Whether you're preparing for litigation or simply assessing a case for its merits, the Medication Safety Audit Tool provides a structured, methodical approach to addressing one of the most critical aspects of healthcare negligence.
Medication Safety Audit Tool
A structured framework for identifying medication errors, compliance failures, and preventable harm across all healthcare settings.
This audit tool helps attorneys evaluate medication administration practices, identify deviations from standards of care, and uncover systemic failures that contributed to patient harm.
Use this tool during case screening, breach analysis, deposition preparation, and expert review.
Medication Reconciliation & Admission Compliance
Required Elements
• Complete medication reconciliation at admission
• Verification of home medications
• Allergy documentation
• High-risk medication identification
• Pharmacy review
Identify Violations
• Missing or incomplete reconciliation
• Incorrect medication list
• Allergies not documented
• High-risk meds not flagged
• No pharmacy involvement
Medication Administration Record (MAR) Audit
Review MAR for Accuracy
• Correct medication
• Correct dose
• Correct route
• Correct time
• Correct patient
• Correct documentation
Identify Red Flags
• Missed doses
• Late doses
• Double doses
• Wrong medication
• Wrong route
• PRN meds without indication
• PRN meds without follow-up documentation
Timeliness & Scheduling Compliance
Required Standards
• Medications administered within required time windows
• Time-sensitive medications prioritized
• Insulin and glucose checks aligned
• Pain meds reassessed within the required timeframe
Identify Failures
• Delayed administration
• No reassessment after pain meds
• Insulin given without glucose check
• Time-critical meds not prioritized
Lab Monitoring & High-Risk Medications
Required Monitoring
• INR for anticoagulants
• Glucose for insulin
• Electrolytes for diuretics
• Drug levels (e.g., vancomycin)
• Renal function for nephrotoxic meds
Identify Failures
• Labs not ordered
• Labs ordered but not drawn
• Abnormal labs ignored
• No provider notification
• No dose adjustment despite abnormal results
Provider Communication & Order Clarification
Required Communication
• Notify provider of abnormal labs
• Clarify unclear orders
• Report adverse reactions
• Report medication refusals
• Document provider instructions
Identify Failures
• No provider notification
• Delayed notification
• No documentation of communication
• Orders not clarified
• Provider unaware of deterioration
Adverse Drug Event (ADE) Analysis
Document Key Details
• Symptoms
• Timing relative to medication
• Interventions performed
• Provider notification
• Reassessment
• Outcome
Identify Contributing Factors
• Wrong medication
• Wrong dose
• Missed monitoring
• Delayed response
• Polypharmacy interactions
• High-risk medication without safeguards
Medication Safety Audits Identify Ordering, Administration, and Monitoring Failures
Medication-related adverse events frequently arise from breakdowns in prescribing, transcription, administration, reconciliation, or monitoring. The Medication Safety Audit Tool evaluates medication practices against physician orders, clinical documentation, regulatory requirements, and accepted standards of care. Our clinical-legal team identifies dosing errors, omissions, contraindications, monitoring failures, documentation gaps, and system-level weaknesses that create patient safety risk, regulatory exposure, and litigation liability.
Submit Records for Medication Safety Audit