handling medication in the perioperative environment

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


Nursing documentation in periop settings


Nursing documentation is…

Evidence of your accountability• Care has been provided• Quality of care meets accepted standards ACORN PS4

A record of events and outcomesAn 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


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.


Policy and guidelines

Requirements for quality documentation• Document fact• Document all relevant information• Document contemporaneously• Maintain the integrity of the

documentation


Medication labelling – multiple contexts


Medication labelling


NSW Poisons Act 1966 & Poisons & Therapeutic

Goods Regulation 2008

MoH PD2007_077Handling of Medication

MoH PD2005_343Medication Admin by EN

Local Health DistrictsMedication Admin: EN

Facility Policies

SESLHD PD209 #Medicine: Managing

Intraoperative Medications

Legislation and policy


NSW Poisons Act 1966 & Poisons & Therapeutic

Goods Regulation 2008

MoH PD2007_077Handling of Medication

MoH PD2005_343Medication Admin by EN

Local Health DistrictsMedication Admin: EN

Facility Policies

SESLHD PD209 #Medicine: Managing

Intraoperative Medications

National R

ecomm

endations for U

ser-applied Labelling


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

http://www.cec.health.nsw.gov.au/clinical-incident-management#PIT




Safe Surgery 2015