Internal documentation to support the service desk when prioritizing tickets.
Example;
Wrong drug prompting:
Drug already given prompting again:
Drug not showing:
Archived drug showing:
Administration of meds not recorded correctly.
Medication errors and safeguarding
The purpose of this section is to provide guidance to care providers on the handling of medication errors and when to consider safeguarding. The same principals apply when considering errors by family carers.
What is a medication error?
The National Patient Safety Agency (NPSA) defines a medication error as an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicine advice, regardless of whether any harm occurred.
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. (National Coordinating Council for Medication Error Reporting and Prevention (www.nccmerp.org).
Medication incidents have a number of causes, such as lack of knowledge, failure to adhere to system and protocols, interruptions, staff competency, poor handwriting and instruction, and poor communication. Errors may result in an incident or an adverse event or where averted they can be classified as a ‘near miss’.
Responsibilities of care providers Care providers who are commissioned to provide any medication administration service within a care plan are responsible for ensuring that people using this service will have their medicines at the times they need them and in a safe way.
Care providers must have clear procedures which include arrangements for reporting adverse events, adverse drug reactions, incidents, errors and near misses relating to medicines. These arrangements should encourage local and where applicable, national reporting and learning and promote an honest, open and fair culture of safety.
Statutory requirements of care providers around reporting medication errors
The registered person must protect service users against the risks associated with the unsafe use and management of medicines, by means of appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines used for the purposes of the regulated activity.
All medication errors should be reported in line with the care providers, management of incidents policy as soon as possible after the incident.
Best practice for the handling of medication errors
The organisation must have clear procedures for staff detailing how a medication error should be recorded. All medication errors including near misses must be recorded. This record must detail the impact of the error, any immediate action taken and record the date, time and names of staff and service users involved.
The error should be reviewed and an action plan put in place to ensure lessons are learnt and the risk of the error being repeated is reduced.
It is also important to review the error in the context of previously recorded errors as a series of similar incidents may meet the criteria for referral into safeguarding.
Examples of errors which may be considered appropriate for referring into safeguarding
any medication error that leads to actual harm or death
any medication error that exposes the adult at risk to unacceptable risk of harm
any medication error requiring medical intervention e.g. GP consultation, attendance at A&E
the medication error was a deliberate act
medication is administered covertly without appropriate consultation/supervision
the medication error is part of a pattern or culture.
The pattern could be same drug, same carer or same vulnerable person. The duration and frequency must be considered Staff should be aware of their own organisation’s policies and procedures on medication management and other relevant local and national guidelines, protocols and policies e.g. NICE guidance, NMC, incident reporting policies. The decision as to whether there should be a safeguarding investigation is made in line with the procedure set out in Part 2 of this document.
Medicines-related problems
Commissioners and providers should ensure that a robust process is in place for identifying, reporting, reviewing and learning from medicines errors involving residents.
Care home staff should report all suspected adverse effects of medicines to the prescriber or another health professional as soon as possible; this would usually be the GP or out-ofhours service. Staff should record the details in the resident's care plan and tell the supplying pharmacy (with the agreement of the resident).
Safeguarding
¨ Care home providers should have a clear process in the medicines policy for reporting medicines-related incidents under local safeguarding processes. It should clearly state: when to notify the CQC (or other appropriate regulator), which medicines-related safeguarding incidents to report and when, that accurate details of any medicines-related safeguarding incidents are recorded as soon as possible.
¨ Care home providers should record all medicines-related safety incidents, including all 'near misses' and incidents that do not cause any harm.
¨ Local safeguarding processes should include investigating each report of a medicines-related safeguarding incident and monitor reports for trends.
¨ Care home staff should contact a health professional to ensure that action is taken to safeguard any resident involved in a medicines-related safeguarding incident. They should follow an agreed process which sets out who to contact in normal office hours and out-of-hours.
¨ Care home staff should; find out the root cause of medicines-related incidents, give residents and/or their family members/carers information on how to report a medicines-related safety incident or their concerns about medicines, using the care home provider's complaints process, local authority (or local safeguarding) processes and/or a regulator's process.