Medication Pass Observation Audit

Direct observation audit of a licensed nurse completing a full medication pass, with emphasis on medication administration accuracy, documentation, patient safety, and error-rate tracking.

Audit Setup and Scope

• Observer identified the nurse, unit, date, and med-pass start time
• Observation scope confirmed as a full medication pass
• Resident census / number of medication administrations observed
• Medication pass policy or facility procedure referenced

Right Resident and Order Verification

• Two resident identifiers verified before each medication administration
• Medication matches the current MAR/TAR and active order
• Allergies reviewed before administration when applicable
• Medication, dose, route, and time verified against the order

Administration Technique and Safety

• Hand hygiene performed at appropriate points during the med pass
• PPE used when indicated by resident condition or medication handling requirements
• Medication prepared and administered without interruption or mix-up
• Controlled substances handled according to policy when applicable
• Resident observed for immediate adverse reaction or refusal after administration

Documentation and Timeliness

• Medications documented on the MAR immediately after administration or per policy
• Late, held, refused, or omitted doses documented with required reason
• PRN medication documentation includes indication and follow-up effectiveness when applicable
• Documentation legible, complete, and consistent with observed administration

Medication Error and Variance Tracking

• Number of medication errors observed
• Number of near misses or intercepted errors observed
• Observed error rate calculated as errors divided by total administrations
• Variance escalated to charge nurse, supervisor, or per facility policy

Closeout and Corrective Actions

• Overall audit result
• Corrective action plan documented for any deficiency or non-conformance
• Follow-up audit or re-education scheduled if needed
• Inspector signature