Standards for medicines related incidents

1 Aim

The aim of this document is to set down the standards for medicines related incidents.

The purpose of the policy is to engender a safe approach to the supply, storage, use and administration of medicines.

2 Link to overarching policy and, or procedure

This document links to the overarching safe and secure handling of medicines manual.

3 Definition of a medication incident or error

A medication error is a preventable incident associated with the user of medicines, which may lead to patient harm. Such incidents may be related to any of the steps of the medicines process of the medication user, the following is a list of common, but not exhaustive examples.

4 Types of medication errors

4.1 Prescribing errors

Omission of regularly prescribed medication.
Drug or dose selection.
Route or time of administration.
Illegible or incomplete prescriptions.

4.2. Dispensing errors (supply)

Wrong drug.
Wrong dose.
Wrong quantity.
Wrong formulation.
Unavailability of dose for administration at scheduled time.
Dispensing out of date drug.
Dispensing an incorrectly formulated drug.
Absence of patient information leaflets in to take out (TTO) medications.

4.3 Administration errors

Administering the drug to the wrong patient.
Administering the wrong drug.
Administering the wrong dose.
Administering the drug at the wrong rate.
Administering via the wrong route.
Administering the drug at the wrong time.
Non-justifiable omission of the dose.
Administering an out of date drug.
Administering an incorrectly formulated drug.

5 Patient care when an error occurs

5.1 Patient counselling

Failure to counsel a patient on the accurate use of their medicines.

5.2 Patient monitoring

Failure to monitor the appropriate patient parameters, to ensure the safe and effective use of a drug.

Dispensing errors, for example, errors in the supply of a medication to the ward or department should also be reported directly to the relevant pharmacy.

Errors are often made under pressure of work, or by failure to follow policies. It is essential that an atmosphere of openness prevail so that staff who realise any mistakes feel able to report them to avoid any detrimental effects on patients.

6 Action to take if an error occurs

The staff member who discovers the error must:

maintain the patients safety
inform the appropriate prescriber and seek advice on any action required
review the patient’s care plan in light of any advice given
report the error to the service manager or modern matron
the relevant prescriber’s line manager (or on call cover) is responsible for dealing with prescribing errors concerning the patient. Errors must be discussed with the manager with the knowledge of the prescriber. The manager should discuss significant prescribing errors with the prescriber and the clinical pharmacist. Supporting statements will be required from the staff concerned. The EDMET tool (staff access only) (opens in new window) should be used to help review the error and can be used as a record to review both prescribing and administration errors
in the event of administration errors either as a result of a prescribing or administration error, the patient should be informed and offered reassurance. In the event that the patient has a condition which impairs their cognitive or intellectual functions, the doctor in charge of their care will be consulted so that a decision can be made about informing them and, or their relatives or carers of the error
report the error using the trust’s electronic reporting system (IR1) giving details of the incident, immediate action taken, and any factors which may have contributed to the error
if it is a dispensing error the trust chief pharmacist or nominated deputy will investigate and supporting statements will be require from all staff concerned in the event that the patient, relative or carer are dissatisfied with the outcome of the incident and the trust’s listening and responding to concerns and complaints policy (formally complaints handling policy) will be followed

7 How the organisation learns from medication incidents

All medication incidents and near misses will be subject to review by the trust’s Pharmacy team. Themes and lessons learned from serious incidents (SIs) will be reviewed in the medicines management committee (MMC) and will inform the medicines management training and policy review.

Each month all medicines related incidents are reviewed by the pharmacy team and the trusts medication safety officer (MSO), and a synopsis presented to the MMC. These are then presented to the care group governance meetings for further dissemination. All patient safety incidents will be shared with the trusts Patient Safety Response Framework (PSIRF) team to ensure that there is learning shared from all incidents.

8 Investigation of drug discrepancy or loss occurring in the hospital or community

It is acknowledged that in the community setting prescribed drugs are owned by the patient; however the following will apply throughout the trust.

Any knowledge or suspicion of drug loss or discrepancy of drugs, for which the staff member is responsible for administering and recording the balance of, must be reported immediately to the responsible person, and pharmacy team and their line manager. Discretion must apply in all instances.
Where an incident is due to suspected theft or burglary by a person external to the trust, staff will refer to the security manager and the police must be informed.
In all cases an incident form should be completed as per trust incident management policy.
The Pharmacy team will liaise with the relevant manager and investigate accordingly.

Document control

Version: 2.
Unique reference number: 557.
Approved by: Clinical policy review and approval group.
Date approved: 6 October 2023.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Executive medical director or medicines management committee.
Date issued: 27 October 2023.
Review date: 31 October 2026.
Target audience: Trust wide.
Description of change: Document review.

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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