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Drug/Medicines Errors (Identifying, Reporting and Reviewing Medicines-related Problems) Policy

Policy Statement

This policy describes {{org_field_name}}’s approach (care home or domiciliary care) to situations where mistakes might have occurred in the administration of any medicines to people for which {{org_field_name}} has agreed and accepted responsibility for.

The object of the service’s medicines’ policies is always to ensure medicines are given safely in the prescribed manner, so this policy applies to the occasional failures to follow agreed procedures or where mistakes may have occurred accidentally. The further object is always to learn from any mistake so that there is no recurrence.

The policy is written in line with the requirements of the applicable legislation governing medicines, national health and social care standards, and best practice guidance issued by the National Institute for Clinical and Health Excellence (NICE) for medicines administration on both care homes and community settings and The Royal Pharmaceutical Society and NHS bodies.

Principles

NICE guidance recommends that care providers implement any local action plans for improving the safety of people using services by always finding out the root causes of any medication errors and correcting them.

{{org_field_name}} considers that its administration of medication policies and procedures are sufficiently rigorous so as to prevent mistakes from being made. However, the following procedures will always be followed in the event of a mistake being discovered or a near-miss, or where there is any slip-up in procedures.

The medicines error investigatory procedures are used even when a mistake has been discovered early enough to prevent any harm. All mistakes, including near-misses, are recorded and the records made available to inspectors and local commissioners as required.

Medication-related incidents that have resulted in harm to a resident will be notified to the care inspectorate under its notification procedures and could be reported to the local safeguarding adults authority for investigation and further action.

{{org_field_name}} is also committed, in line with Duty of Candour, to communicating to people and their representatives any significant mistakes it might have made and to engaging them in the process of inquiry and remedial action.

{{org_field_name}} informs people and their representatives that they should use the complaints procedure if they consider that the service has not acted sufficiently rigorously on the matters that have been raised or they have not been kept adequately informed of or engaged in the issues as they are being addressed.

Procedures

{{org_field_name}} is aware that medication errors can happen even in the best-run care service. Mistakes include incidents where medication is given to the wrong person, where the wrong medicine is given or where the wrong dose is given. The investigation that follows will always work systematically through the whole process of medication administration in order to find the source of the error and to identify the actions needed to put the matter right and to prevent any future occurrence.

Initial investigations will usually be carried out or arranged by the registered manager, who will draw on expert advice and guidance as required by the errors being investigated, eg senior nursing and other clinical staff, pharmacist and GP. In some more serious instances or situations where there might be weaknesses in systems, {{org_field_name}} might seek to appoint an independent person who has the necessary qualifications and experience, eg a pharmacist, to carry out the root and branch investigation required.

Where safeguarding matters are being investigated, {{org_field_name}} will follow the policies and procedures set out by the local adults’ safeguarding authority. It will also take into account any requirements of the care inspectorate in response to any notification it has made.

  1. All adverse effects of any medication given to or taken by a person are reported or referred to the prescribing practitioner without delay or are discussed fully with an appropriate healthcare professional such as pharmacist or out-of-hours GP.
  2. All medication errors identified by staff are reported to the person in charge or to a responsible medical practitioner without delay.
  3. It is important that any medication errors be reported immediately if the health and wellbeing of the people we support is to be protected. The rapid reporting of such errors means that prompt medical action can be taken where necessary.
  4. All medication errors are fully and carefully investigated taking full account of the context, the circumstances and the position and experience of the staff involved.
  5. To encourage staff to report drug errors {{org_field_name}} maintains an open “no blame” policy where staff will not be blamed for an error unless they have been found clearly negligent in their duties. If such a policy is not followed, {{org_field_name}} believes that there is a danger of concealment with potentially dangerous results.
  6. In certain circumstances involving trained nursing staff it might be necessary to refer serious errors to the Nursing & Midwifery Council, whose Professional Conduct Committee will investigate. The NMC supports the use of local multidisciplinary critical incident panels to investigate incidents and ensure that lessons are learnt from them.
  7. In particular the NMC will distinguish between errors that are the result of reckless or incompetent practice or where an attempt has been made to conceal the error, and errors which result from pressure of work and where the error has been immediately reported.
  8. The results of any investigation into medicines errors will always be used to inform changes and improvements in the service’s medication administration policies.
  9. Incidents resulting in people being harmed by a medication error should be reported to the care regulator.
  10. Such incidents should also be referred to the local adults’ safeguarding authority for further investigation and possible action under its referral procedures.

Individual Mistakes

Where the mistake or potential mistake involves an individual, {{org_field_name}}’s investigation is based on checking against the six Rs of medicines administration for that person. The procedure is similar to that followed for a routine review of an individual’s medication needs.

  1. Right person: has or would the person be given or be taking (in cases of self-administration) the actual medicine prescribed for that person? The answer could entail checking the prescription(s), ordering and dispensing procedures involved, the list of medicines being taken by the person as stated in their care plan (reconciliation list) and the MAR chart.
  2. Right medicine: has the right medicine been prescribed? This could involve checking the care plan/reconciliation list with the prescribing practitioner and pharmacist to make sure that all medicines are fit for purpose and are compatible with one another. Any medicines taken as required or over-the-counter medicines used by the person will also be checked for possible adverse effects.
  3. Right route: are the medicines in a form that enables the person to obtain maximum benefit from them, eg if taken orally? Do they have difficulty swallowing tablets? This will involve checking their abilities and preferences against the prescribing practices to assess that the prescribed route is compatible with their ability to follow the prescribed route.
  4. Right dose: has the person been given or taken the correct dosages? This again will involve checking MAR charts against prescriptions, etc.
  5. Right time: has the medicine been given or taken at the times prescribed? This again will involve checking MAR charts against prescriptions, etc.
  6. Resident’s right to refuse: has the person refused to take the medication as prescribed? A yes answer will mean further assessment of the individual’s reasons and their capacity to take their own decisions.

Self-administration

Where the mistake has been made by or in connection with a person who is responsible for taking their own medication, the same process as described above will apply. {{org_field_name}} will also review the individual’s capacity to self-administer, the risks involved and whether these have changed.

Checking the Medicines Administration System

Whenever a mistake is identified for one or more people, {{org_field_name}} will also make wider system checks to ensure that others are taking their medicines safely.

It will therefore make checks on:

Implementation

All staff are responsible for the implementation of this policy. Overall responsibility for ensuring the policy is implemented, monitored and reviewed rests with the registered manager.

Information on the policy is:

Training

All staff are provided with training covering basic information about common medicines and how to recognise and deal with medication problems or errors.

Nursing staff are expected to keep themselves up to date as required in their revalidation process and as specified in their professional code of conduct (The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, October 2018).

All staff are instructed on how medicines-related incidents procedures are set in motion and the part that they might play in the event of being directly implicated or involved.

Senior staff with responsibilities for monitoring and reviewing medicines administration and for investigating mistakes under this policy will be provided with additional training.


Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

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