MEDICATION SAFETY AUDIT TOOL
A structured framework for identifying medication errors, compliance failures, and preventable harm across all healthcare settings.
Medication errors are a leading cause of preventable injury in healthcare. 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
DOCUMENTATION AUDIT
✔ Required Documentation
• Medication administration
• PRN indication and follow‑up
• Provider notifications
• Adverse reactions
• Refusals
• Education provided
✔ Identify Failures
• Missing documentation
• Contradictory entries
• Late entries
• No follow‑up documentation
• No explanation for missed doses
GLOBAL MEDICATION SAFETY RED FLAGS
• Missed or late doses
• No documentation of PRN effectiveness
• High‑risk meds without monitoring
• Abnormal labs ignored
• No provider notificatio
• Contradictory MAR entries
• Medication given despite contraindications
• No reassessment after interventions
• Polypharmacy without oversight
• No documentation of refusals or reactions
These are some of the strongest breach indicators in medication‑related negligence cases