Standard Operating Procedure for Medicine errors in care homes within NHS Sutton CCG Introduction All health and social care organisations are accountable for ensuring the safe administration of medicines. A medication error is an error in the process of prescribing, dispensing, preparing and administering regardless of whether any harm occurred. This procedure is intended to ensure that the correct action is taken quickly, records are kept of the actions taken and the appropriate people are informed. Organisation within which the SOP applies: All Care homes receiving medicines from community pharmacies and receiving clinical support from GP practices within NHS Sutton CCG Objectives / Purpose To ensure that the correct procedures happen in the correct order to minimise harm to the service user To ensure that the appropriate people are informed of the error immediately or as soon as possible To provide a clear and auditable process to record errors in the home When medication errors are identified and action taken to prevent re-occurrence and encourage learning Scope This Standard Operating Procedure applies to Managers, Nurses and care staff working within Care Homes in NHS Sutton CCG who are responsible for medicines Responsibilities Staff working in the areas who have a responsibility the safer management of medicines in care homes within NHS Sutton CCG Related Guidelines and Standing Operational Procedures Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities 2009) Regulation 2010 THE HANDLING OF MEDICINES IN SOCIAL CARE Royal Pharmaceutical Society November 2007 The Health and Social Care Act 2008 (regulated activities) Regulations 2014. Safe Care and treatment. Regulation 12 Review Period September 2018 or earlier if indicated Validation process: This guidance has been approved by Sutton and Merton MMC for use in care homes within NHS Sutton Clinical Commissioning Group 1
Author and contributors: Hai To, Care Home Pharmacist, NHS Sutton CCG Acknowledgement: Tania Cook, Specialist Senior Medicines Management Technician Social Care Lead, NHS Nottingham City CCG Date Approved: September 2016 2
Process A medication error is an error in the process of prescribing, dispensing, preparing, administering, monitoring, or providing medicine advice, regardless of whether any harm occurred. Responsible Person Designated Nurse or Home Manager/ Senior Carer Examples of administration errors can include the following: 1. Omissions any prescribed dose not given 2. Wrong dose administered, too much or too little 3. Extra dose given 4. Unprescribed medicine the administration to a resident of any medicine not authorised for them 5. Wrong dose interval 6. Wrong administration route administration of a medicine by a different route or in a different form from that prescribed 7. Wrong time for administration 8. Not following warning advice when administering e.g Take with or after food 9. Administration of a drug to which the resident has a known allergy 10. Administration of a drug past its expiry date All medication errors, incidents and near misses should be reported to the duty manager to inform them what has happened and also what action has been taken to rectify the immediate situation and what has been done to prevent it happening again. All notifiable incidents should be reported to the CQC. The results of these regular investigations should be recorded including any actions taken such as offering training to individuals or reviewing existing procedures. Regular meetings should be held with all staff involved with handling and administering medication review the outcomes and investigations of errors share learning points and prevent reoccurrence of similar errors. A care home should also log any incidents that occur as result of errors made as part of the prescribing or dispensing process, for example, by GPs or community pharmacists. Such errors should be discussed with the GP or community pharmacist. 3
Process When a medication error occurred, confirm if it has caused harm or not. Follow the plan of actions below accordingly: Responsible Person Actions: Medication error that has caused harm to the service user Following a medication error if the service user is unwell, call the Emergency Services If the service user is not unwell, call their GP to inform them of the error and to ask what action (if any) they would like you to take If the GP is unavailable, contact 111 and act on their advice Record any observations of the service user that have been made since the incident took place Report to the safeguarding team at London Borough of Sutton on xxxxxx or email xxxxxxx or contact them for advice Report to AQP (if on AQP) Contact the duty manager or the carer/nurse in charge of the home immediately or as soon as possible to inform them of what has happened and what actions have been taken in response to the error Inform the service users relatives so that they are aware of what has happened Make a written report describing what happened and actions taken Report these incidents to CQC (Care Quality Commission) Manager/responsible person to hold a review meeting for all care staff to investigate the incident to identify learning in order to prevent reoccurrence If the medication error was a dispensing error then, the dispensing pharmacy needs to be informed If the medication was a prescribing error then the prescribing surgery needs to be informed Actions: Medication error that has NOT caused harm Record the incident in the medicines reporting log Manager/responsible person to hold a review meeting for all care staff periodically e.g. monthly, to investigate the incident to identify learning in order to prevent re-occurrence. If the medication error was a dispensing error then, the dispensing pharmacy needs to be informed If the medication was a prescribing error then the prescribing surgery needs to be informed 4
I have read and understood this standard operating procedure and agree to work to it. Name Job Title Signature Date Home Manager 5