definition of medicines management incidents reported how medications errors are reported actions...
TRANSCRIPT
Definition of medicines management Incidents reported How medications errors are reported Actions taken to prevent reoccurrence Role of the Supervisor in relation to
medications errors.
The administration of a medicine is a common but important clinical procedure. It is the manner in which a medicine is administered that determines the outcomes for the patient. Eg: clinical benefit or adverse effect.
The administration of medicines has been demonstrated to encompass many areas for potential error.
In 2013 there were 6 reported medicines incidences.
Most of these were ward related. Most of these were simple mistakes from not
checking prescribed dosage and names of medications properly.
These were reported through IR1’s and investigated accordingly.
Governance. Risk Management Midwife. Ownership. Ward Manager/Team Leader reporting same. Other staff or women themselves. Complaints management.
Risky business – highlights most frequent incidents of medications errors
Wrong dose/wrong strengthOmitted medicineIncorrect drug administeredMedication stored in wrong package
Regular SOM medications audit of controlled drugs
Medication errors highlighted at SOM road shows
Governance management PHA Midwives and Medicines leaflet
NMC standards for Medicines Management 2010
Adherence to Trust policies and guidelines Mentorship support for student midwives
Action plan. ◦ Reflective practice◦ Observed medication administration assessment
tool◦ Medicines Management update through C.E.C.◦ Self assessment of medication knowledge tool◦ Good record keeping.(NMC 2012).
Activity Action 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
Check Medicine Medicine available (if not arrange supply)
Name of Medicine
Strength
Form
Expiry Date
Opens one pack at a time
Removes dose (‘non-touch’)
Returns container to trolley or replaces / orders if last dose
Administration to patient Check patient hasn’t had dose
Check patient’s condition – should medicine be withheld?
Check patient’s identification
Check patient’s allergies
Take medicines to patient and remain until doses taken
Interaction with patient person centred
Documentation Make accurate record AFTER administration
Date & Time
Nurse’s Initials
Record omission using reason code
Prescription Patient Name
Unit Number
Name of Medicine
Dose (within normal limits)
Route
Timing and Frequency (fits with expected time of administration)
Start date
Signature
Allergies (used to check medicine)
‘Lessons Learnt’. We cannot become complacent We are accountable practitioners Be careful!!!