Handling medication in the perioperative environment
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This document discusses a nursing education session on perioperative documentation, medication labelling, and patient identification. The key points are: - The session aims to discuss principles of nursing documentation in perioperative settings, labelling of medicines and lines, and using surgical safety checklists for patient ID and procedure matching. - Nursing documentation provides accountability, records events and outcomes, explains clinical decisions, and enables continuing care. It must be accurate, non-judgemental, and contemporaneous. - Medication labelling must follow various legislation, policies, and guidelines to ensure patient safety in multiple clinical contexts including perioperative settings. - Incident reports show importance of documentation, medication safety, and human performance for patient
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Handling medication in the perioperative environment
- 1. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Learning Outcomes By the end of the session, you should be able to: • Discuss principles, policy and practices for • Nursing documentation in perioperative settings; • Labelling of medicines, fluids and lines; and • Patient ID and procedure matching using the surgical safety checklist • Identify how these topics affect YOU and consider the implications for your practice as the agency perioperative nurse; and • Locate and access further information
- 2. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Nursing documentation in periop settings
- 3. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Nursing documentation is… Evidence of your accountability • Care has been provided • Quality of care meets accepted standards ACORN PS4 A record of events and outcomes An explanation of your clinical decisions and judgements A communication tool between • Healthcare practitioners • Patient’s family and friends THE GARLING REPORT • Auditors, researchers and investigators Enables the provision of effective continuing care
- 4. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. NMBA Code of Ethics 2008 Value Statement 7: Nurses value ethical management of information The generation and management of information (including health care records and other documents) are performed with professionalism and integrity. This requires the information being recorded to be accurate, non-judgemental and relevant to the health, care and treatment of a person. All health documentation is a record that cannot be changed or altered other than by the addition of further information.
- 5. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Policy and guidelines Requirements for quality documentation • Document fact • Document all relevant information • Document contemporaneously • Maintain the integrity of the documentation
- 6. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Medication labelling – multiple contexts
- 7. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Medication labelling
- 8. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. NSW Poisons Act 1966 & Poisons & Therapeutic Goods Regulation 2008 MoH PD2007_077 Handling of Medication MoH PD2005_343 Medication Admin by EN Local Health Districts Medication Admin: EN Facility Policies SESLHD PD209 # Medicine: Managing Intraoperative Medications Legislation and policy
- 9. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. NSW Poisons Act 1966 & Poisons & Therapeutic Goods Regulation 2008 MoH PD2007_077 Handling of Medication MoH PD2005_343 Medication Admin by EN Local Health Districts Medication Admin: EN Facility Policies SESLHD PD209 # Medicine: Managing Intraoperative Medications NationalRecommendations forUser-appliedLabelling
- 10. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved.
- 11. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Incidents up from 66,000 to 75,000 in 2 years Incidents include: Clinical management, Medications, Pressure Injury, Human Performance, Documentation and HCA Infections Incident Data 2011-2012 from the CEC http://www.cec.health.nsw.gov.au/clinical-incident-management#PIT
- 12. Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved. Safe Surgery 2015