management of nursing and midwifery medication errors/near … · 2017-05-30 · training and...

Database No: 558 of 19 Version 1

Management of nursing, midwifery medication near misses policy Please check that this is the most up to date version of this written control document

Management of Nursing and Midwifery Medication Errors/Near Misses Policy

Policy Number:

558 Supersedes: Classification Clinical

Version No

Date of EqIA:

Approved by: Date of

Approval: Date made

Active: Review Date:

V1 24th March 17

W&OD sub committee 18-5-17 30-5-2017 18-5-2020

Brief Summary of Document:

Management of Nursing and Midwifery Medication Errors/Near Misses Policy has been developed to support staff in the management of decision making following an error or near miss. .

Scope:

This policy will be utilised across the HDUHB Acute and Community settings. The policy is developed to support nursing and midwifery staff. Nurses and midwives across the HDUHB will be advised by the content of this policy.

To be read in conjunction

with:

176 - Non Medical Nurse Prescribing Policy 268 - Medicines Policy 201 - Disciplinary Policy 203 - All Wales Capability Policy 136 - Positive Patient Identification Policy 244 – Being Open Policy 098 – Safeguarding Adults at Risk Policy

Owning Group

SNMT, Workforce and Organisational Development, MERG

Executive Director:

Mandy Davies

Job Title Interim Director of Nursing

HYWEL DDA UNIVERSITY HEALTH BOARD



Reviews and updates

Version no: Summary of Amendments:

Date Approved:

1 New policy

Glossary of terms

Term Definition

RN Registered Nurse

MERG Medicines Event Review Group

QSEAC Operational Quality, Safety and experience Sub Committees

KEY WORDS

Medication, Errors, Near Miss, Repeated Errors, Safeguarding, Risk Categorisation, Datix Competency Assessment




CONTENTS

Contents 1. INTRODUCTION ................................................................................................................... 4

2. POLICY STATEMENT........................................................................................................... 4

3. SCOPE .................................................................................................................................. 4

4. AIM ........................................................................................................................................ 4

5. OBJECTIVES ........................................................................................................................ 4

6. DEFINITIONS/TERMINOLOGY ............................................................................................ 5

7. RECOGNITION AND IMMEDIATE MANAGEMENT OF A MEDICATION ERROR / NEAR MISS ............................................................................................................................................ 6

8. NEXT STEPS ........................................................................................................................ 7

9. LEARNING FROM EVENTS ................................................................................................. 9

10. NMC REFERRAL ............................................................................................................... 9

11. RESPONSIBILITIES ........................................................................................................ 10

11. REFERENCES................................................................................................................. 10

12. APPENDIX 1A - RISK CATEGORISATION OF ERROR/NEAR MISS ............................. 11

13. APPENDIX 1B- DRUG ERROR DECISION TREE APPENDIX 1B (ADAPTED FROM NPSA GUIDANCE) .................................................................................................................... 12

14. APPENDIX 2 – INCIDENT REVIEW FORM .................................................................... 13

15. APPENDIX 3 - REFLECTION AND LEARNING TEMPLATE........................................... 14

16. APPENDIX 4 - TEMPLATE TO RECORD DECISION FOLLOWING REVIEW OF „INITIAL ASSESSMENT OF FACTS‟ ......................................................................................... 15

17. APPENDIX 5 - MEDICINES POLICY (ACUTE, MENTAL HEALTH, LEARNING DISABILITIES AND COMMUNITY SERVICES) ........................................................................ 16

18. APPENDIX 6 - DRUG ADMINISTRATION ASSESSMENT ............................................. 17




1. INTRODUCTION ‘Millions of medicines are prescribed in the community and in hospitals across England and Wales each day – the majority of these are delivered correctly and do exactly what they are meant to do. However, when an incident does occur, it is vital we learn from this to ensure patients are not harmed’. (National Patient Safety Agency (NPSA), Tackling Medication Incidents and Increasing Patient Safety, 2009. A medication error can pose a threat to the patient as well as the organisation. The member of staff who made the error can also be affected. The following procedure describes how to manage medication errors consistently, including the immediate actions to consider in addition to medium and long term action planning. 2. POLICY STATEMENT Hywel Dda University Health Board (HDUHB) encourages a sensitive response to medication errors through a comprehensive assessment which takes full account of the context and circumstances surrounding the incident. It is recognised that it is important to support staff when they have been involved in a medication error/near miss as it can cause distress and concern for practitioners in particular when there is a direct impact on patients. 3. SCOPE This policy applies to all registered nurses and midwives (including bank and agency nurses or midwives, and also to pre-registration nursing and midwifery students page 7), who work within the HDUHB. It sets out guidance on the definitions of preparation, administration, monitoring and storage errors. It seeks to outline the scope of the actions to be taken to ensure a consistent, fair and equitable management of staff in response to a drug error or near miss, including both the immediate management of the incident and the longer term follow up. 4. AIM The policy aims to recognise the potential differences that may be required when managing staff involved in a single medication error as opposed to repeated failure to respond to support, training and supervision relating to safe medication practice; and it will address the support that will be provided to staff in all circumstances. 5. OBJECTIVES The principle objectives of this policy are to:-

Ensure the immediate and long term safety of the patient;

Support the member of staff who made the error/near miss in an individualised manner so that the risk of such errors recurring are minimised as far as possible;

Identify any environmental / systems factors that may have contributed to the error / near miss;

Provide guidance for Ward Sisters and Senior Nurses when dealing with staff who have made an error / near miss; ensuring that these staff attend the Medicines Management study day developed for staff who have conducted an error/near miss;

Provide a framework for assessing errors/near misses so that staff are dealt with fairly and consistently in a timely manner;

Ensure the mandatory training requirement, in relation to Medicines Management, is supported on a 3 yearly basis;

Ensure that the organisation learns lessons from the error/near miss in order to minimise similar occurrences in the future.




6. DEFINITIONS/TERMINOLOGY 6.1 Safeguarding People Medication errors are not defined, as such, on the basis of the harm caused to a patient but rather the definition of an error relates to the deviation from the safe system that has been established (see HDUHB Policy no. 268. Medicines Policy) in order to maintain patient safety relating to practice associated with medication administration. If it is suspected that a registered nurse (RN) wilfully neglected to administer a medicine whether or not the person affected is deemed an adult at risk then a Safeguarding Referral must be discussed with the HDUHB adult safeguarding team. Part 7 of the Social Services and Well Being (Wales) Act 2014 sets out the legal definition of abuse and neglect and the legal definition of „Adult at risk‟ (see HDUHB Policy 098 - Safeguarding Adults at Risk Policy). There are criminal offences for ill treatment and wilful neglect whereby individual professionals and/or organisations can be prosecuted. - Section 44 of the Mental Capacity Act 2005 involves an offence of ill treatment and wilful

neglect of a person who lacks capacity; - Section 127 of the Mental Health Act involves an offence of ill treatment or wilful neglect of

an individual detained under the Mental Health Act 2005. - Sections 20 and 21 of the Criminal Justice and Courts Act 2015 involve an offence of ill

treatment or wilful neglect of an individual by a care worker irrespective of a persons‟ capacity. This latter offence also includes an offence for provider organisations and will focus on the alleged failings of an organisation.

If it is suspected that the action/omission involved ill treatment or wilful neglect; there was a conscious disregard for the risks involved in a drug administration incident by the Registrant, regardless of harm to the person affected, the Police must be informed. The Social Services and Well Being Act 2014 (Part 7) has formulated a new legal definition of „Adult at risk‟ (the term „Adult at risk‟ will replace the term Vulnerable adult). For awareness, the definition of an adult at risk within this document is; “…An adult who- a) is experiencing or is at risk of abuse or neglect, b) has needs for care and support (whether or not the authority is meeting any of those

needs), and c) as a result of those needs is unable to protect himself or herself against the abuse or

neglect or risk of it”. 6.2 Medication errors can broadly categorise as follows;

Administration without valid authorisation

Patient was administered the wrong medication/dose/route

Patient is administered medication to which they have a recorded allergy

Medication administered late/early *

Patient administered an out of date medication

Medication administered to the wrong patient

Medication omitted without a clinical rationale

Failure to record a rationale for non administration of medication

Medication incorrectly prepared

Incorrect infusion rate




Failure to sign the Medication Chart after administration of medication

Failure to comply with the HDUHB policy in relation to Controlled Medication (268 - Medicines Policy, p23, 6.2.3)

Inappropriate administration of „as required‟ medicines *HDUHB recognises this is a complex issue and the full context of late/early or over use and misuse of medication administration should be taken into account, however where it would have a significantly detrimental effect on patient care, this would constitute a drug error. 6.3 Monitoring Errors

Inappropriate monitoring/follow up

Failure to monitor therapeutic levels

Failure to monitor patients/carers self medication

The Quality and Safety team review Datix reports per site in relation to monitoring

Audit through Fundamentals of Care (Dashboard) conducted by pharmacist. 6.4 Storage and other Errors

Failure to appropriately store medication in locked cabinets and / or refrigerator / Controlled Drug cabinet

Failure to communicate effectively to ensure medication safety of the patient / client. 6.5 Near Miss

The definition of a medication error also includes „near miss incidents‟, ie, when an error would have occurred but for the intervention of something or someone. The HDUHB recognises that it can be as important to report a near miss as an actual error. Near misses indicate difficulties that may be due to incorrect or missing procedures being in place and, as such, it is important that these are reported and recorded. Although staff may only see an isolated incident within their clinical area, there may be a wider picture across the HDUHB indicating a situation that requires action/intervention. The NPSA (2007) discuss a „near miss‟ as “another group of medication incidents will not have caused harm but will be judged to have the potential to cause harm, and these types of incidents are often called „near misses‟. These reports provide valuable insight into where systems need to be improved to prevent death or serious harm. They are important as patients with different susceptibilities may suffer harm from the same incident. See Medicines Policy (268) for Incident Reporting Triggers via link below http://howis.wales.nhs.uk/sitesplus/documents/862/268%20-%20I.%20medication%20incident%20reporting%20trigger%20list.pdf

7. RECOGNITION AND IMMEDIATE MANAGEMENT OF A MEDICATION ERROR / NEAR

MISS The immediate actions to be taken in the event of a medication error/near miss being identified are outlined in the HDUHB‟S 268 - Medicines Policy: http://howis.wales.nhs.uk/sitesplus/862/document/291060 (Acute, Mental Health, Learning Disabilities and Community Services; version6) and Datix Incident Reporting. (Appendix 2)

The line manager / senior nurse manager must be advised what has occurred. A serious incident must be escalated in line with the HDUHB escalation procedures to the Assurance, Safety and Improvement Team.

http://howis.wales.nhs.uk/sitesplus/documents/862/268%20-%20I.%20medication%20incident%20reporting%20trigger%20list.pdf

http://howis.wales.nhs.uk/sitesplus/documents/862/268%20-%20I.%20medication%20incident%20reporting%20trigger%20list.pdf

http://howis.wales.nhs.uk/sitesplus/862/document/291060




If an error / near miss has resulted in actual or potential patient harm, all necessary steps must immediately be taken to ensure patient safety, including notifying the medical team

The patient must be observed and monitored for any adverse event and a review of the patient must be undertaken by medical staff as a matter of urgency.

Advice must be sought from medical/pharmacy staff, as required, and the situation must be reported to the line manager or senior nurse/midwifery manager who should manage the immediate situation from both a patient and a staff perspective.

All controlled medication errors must also be reported to the Accountable Officer for Controlled Drugs (the Medical Director) and the Head of Nursing to the relevant service.

A Datix report must be made for all medication errors including Controlled Drugs.

Where pre registration students are involved in an error/near miss, the University, must also be informed about the error/near miss and be involved in the management of the incident as soon as an error is identified.

Where Bank Nurses are involved in an error/near miss, the Bank Nurse Manager must also be informed about the error/near miss and be involved in the management of the incident as soon as an error is identified.

Where Agency Nurses are involved in an error/near miss, the specific Agency Manager must also be told about the error/near miss and be involved in the management of the incident as soon as an error is identified.

Where there is an error identified relating to a doctor or pharmacist (or other personnel with the ability to prescribe medication to patients) this is also to be captured in a Datix report, ensuring that the prescribers line manager / Consultant is notified of this error.

8. NEXT STEPS

All medication errors/near misses must be fully assessed by the appropriate manager. The initial management plan for the staff member(s) involved in the error/near miss will be influenced by the risk rating of the incident (Appendix 1A); and whether or not they have been involved previously in any other errors/near misses.

Managing medication errors will be part of the medicines management training; staff who make an error are subject to additional training and assessment by their line manager. This must be documented in the nurses‟ personal file.

The management plan must be instigated as soon as possible to capture the incident detail and promote learning within the team and the wider department / site.

In addition to the Datix form being appropriately completed, staff must be reminded to keep the essential equipment (ie syringes, any lines and medication, as below).

If the error involves an infusion device, this must be notified to Electro Medical Equipment and the device removed from service for examination; infusion lines, syringes and medication must be bagged within the area for examination if necessary. The Incident Review Form (Appendix 2) must be uploaded as soon as it is completed to the Datix System.

The Incident Decision Tree (Appendix 1B) will also be used to help to guide consistency in decision making regarding the course of action to be taken.

Using the algorithms in Appendix 1 A/B, should the error/near miss be deemed to (potentially) require investigation / management via the Capability and / or Disciplinary Policy, the professional lead for the service and the Workforce and OD team should be involved to provide advice and support at the earliest stage.

The incident may be managed with support, reflection/supervision and/or further training and competency assessment. The standardised HDUHB-wide medication administration competency assessment tool (Appendix 6) is available through the Ward Sister and is kept




updated by the Senior Nurse Medicine Management. Once the initial facts (Appendix 4) have been gathered, the staff member(s) involved must be asked to complete the Reflection and Learning Template (Appendix 3).

This must be completed within 7 days of the error/near miss. Once completed it must be shared with the appropriate manager and a joint review conducted between the nurse/midwife and the manager, identifying and capturing the lessons learnt for both the individual staff member and the organisation and clearly identifying who is responsible for taking what actions, and in what timescale, as a result of the review.

Staff welfare must be considered during the error/near miss management/investigation process, with appropriate support being offered and made available. This may include establishing support from a named „buddy‟, referral to Staff Psychological Well-Being service, referral to Occupational Health service, or facilitation of Trade Union support.

Copies of all completed documentation (Appendix 2, 3 and 4) relating to the error/near miss must be kept in the nurses‟ personal file. These demonstrate that effective management and support has taken place; and that effective professional development and learning has been identified and facilitated. The purpose of preparing a reflective account is developmental and not punitive; however, this documentation may be referred to as evidence of previous support/action/learning should repeated errors of the same/similar nature occur.

8.1 Repeated Medication Errors

Staff who make more than one medication error, may require additional training, supervision and support.

In cases where nursing/midwifery staff make repeated errors despite training and support, it is likely that the Ward Manager will need to consider formal action in accordance with either the All Wales Disciplinary Policy or the All Wales Capability Policy. Advice will be sought from the appropriate workforce team.

The All Wales Disciplinary Policy (201) states that:-

Failure to meet required standards of performance and behaviour as expected within the employee‟s role and responsibilities.

Failure to comply with local or department rules relating to performance, safety or conduct.

Serious failure to meet required standards of performance and behaviour as expected within the employee‟s role and responsibilities.

The seriousness of the offence (and therefore the culpability of the employee) will depend on the individual circumstances and consequences of each case, but particular consideration will be given to the implications or resultant consequences of the offence; whether the offence is persistent; or whether a previous warning has been issued for the same or related offence(s)....

The All Wales Capability Policy (203) and the procedures are designed to work with those cases where the employee is lacking in some area of knowledge, skill or ability, resulting in a failure to be able to carry out the required duties to an acceptable standard.

The Ward Sister is advised to gain appropriate support from their Senior Nurse Manager, Head of Nursing, Head of Nursing (Acute Services) and Human Resources if either of these policies directives are required. http://www.wales.nhs.uk/sitesplus/documents/862/201-DisciplinaryPolicy%26Procedure-version3.pdf http://www.wales.nhs.uk/sitesplus/documents/862/203-AWCapabilityPolicy2013-ext13.9.16.pdf

http://www.wales.nhs.uk/sitesplus/documents/862/201-DisciplinaryPolicy%26Procedure-version3.pdf

http://www.wales.nhs.uk/sitesplus/documents/862/201-DisciplinaryPolicy%26Procedure-version3.pdf

http://www.wales.nhs.uk/sitesplus/documents/862/203-AWCapabilityPolicy2013-ext13.9.16.pdf

http://www.wales.nhs.uk/sitesplus/documents/862/203-AWCapabilityPolicy2013-ext13.9.16.pdf




8.2 Communications with Patient (Parent/Next of Kin)

HDUHB acknowledges that when things go wrong, open and honest communication with the patient (and/or parent/guardian/next of kin) is fundamental to the ongoing partnership with them.

Following introduction of duty of candour legislation in 2015 the HDUHB must inform, and apologise, to patients if there have been mistakes in their care that have led, or could have led, to significant harm.

The patient (parent/guardian/next of kin) must be informed by nurse in charge, line manager and the doctor in charge of the patient‟s care at that moment in time. If appropriate an apology should be given and documented, acknowledging that an apology is not an admission of liability.

If appropriate, following the investigation, a meeting will be offered to the patient (parent/guardian/next of kin) with the relevant clinician(s) / Senior Nurse. In line with the HDUHB Policy 244 - Being Open Policy, the purpose of such a meeting would be to discuss the findings of the investigation, share the lessons learned and outline the recommendations, put into place, to reduce the risk of a similar incident re-occurring in the future.

8.3 Long Term Actions

Learning from errors/near misses must be shared across all services of the HDUHB. The HDUHB Medicines Event Review Group (MERG) has a responsibility to review information on medication errors using reports generated via the Datix Incident reporting system. The MERG is required, on behalf of the Medicines Management group, to identify any themes and trends within errors/near misses. All staff have a responsibility to highlight and escalate, to MERG, any concerns regarding medication errors/near misses for further investigation, through the Senior Nurse Manager / Head of Nursing.

A quarterly assurance report on medication errors/near misses will be provided to the medicines management group by MERG, with exceptions/issues of concern also being flagged to Medicines Management Group via the Operational Quality, Safety and experience (QSEAC) Sub Committees. The assurance reports presented at the operational QSEAC are also reported at the HDUHB‟s QSEAC as necessary.

9. LEARNING FROM EVENTS

The policy provides the HDUHB guidance which seeks to ensure that learning from medication errors/near misses takes place at both the individual and systemic level; and that such learning is shared and adopted in a consistent manner across the HDUHB. Learning from Events includes identifying key safety and practice issues identified which directly contributed to the incident from which we can learn to prevent the concern from recurring. http://howis.wales.nhs.uk/sites3/Documents/932/Guidance_%20how%20to%20learn%20lessons%20from%20concerns%20version%20issued%2024.1.13.doc

10. NMC REFERRAL

It is essential that any potential NMC Referrals are discussed with the Head of Nursing Acute Services, Workforce Team and the Assistant Director of Nursing (Practice).

https://www.nmc.org.uk/globalassets/siteDocuments/NMC-Publications/NMC-Complaints-against-nurses-and-midwives.pdf

http://howis.wales.nhs.uk/sites3/Documents/932/Guidance_%20how%20to%20learn%20lessons%20from%20concerns%20version%20issued%2024.1.13.doc

http://howis.wales.nhs.uk/sites3/Documents/932/Guidance_%20how%20to%20learn%20lessons%20from%20concerns%20version%20issued%2024.1.13.doc






11. RESPONSIBILITIES 11.1 Chief Executive The provision of resources to ensure compliance with the Medicines Policy (268) and therefore to support the prevention of medication errors / incidents is the responsibility of the Chief Executive and Board. It is their responsibility to ensure that guidance, enclosed within this policy, is consistent with the legal requirements, NHS and Welsh Government local Health Board guidance. Hywel Dda University Health Board is committed to promoting good employee relations and allows all employees‟ access to impartial advice consistent with employment law, equality and human rights legislation, good practice, and includes the right to defend themselves and present their case when errors occur. 11.2 Director of Nursing The Director of Nursing is responsible for the implementation and review of this policy in consultation with other Healthcare professionals.

11.3 Heads of Nursing It is the responsibility of Heads of Nursing to:

Ensure practice in line with HDUHB Medicines Policy (268).

Take responsibility for the local management of errors and near misses in a fair and consistent

manner.

Ensure that a verbal report is provided for all serious untoward incidents to the Assurance, Safety and Improvement Team prior to completion of the Serious Incident (SI) Notification Form.

Encourage a culture where incident reporting is seen as a positive response.

Support staff and encourage an active lead in being open with patients when errors have occurred or patients have been harmed.

11.4 Senior Nurse Managers

The Senior Nurse Managers are responsible for the dissemination of this Policy, monitoring the implementation and auditing adherence to the Policy.

Work with the Ward Manager / Nurse in Charge to ensure patient safety; discuss any incidents with the patient/ family; report incidents promptly via a Datix; notify the Head of Nursing to update on the incident.

11.4 All Clinical Staff must adhere to this policy. 11. REFERENCES

National Patient Safety Agency (NPSA) Safety in Doses: medication safety incidents in the NHS, 2009 http://www.nris.npsa.nhs.uk/resources/patient -safety-topics/medication-safety/

NMC Code 2015

NMC Revalidation 2015

http://www.nris.npsa.nhs.uk/resources/patient%20-safety-topics/medication-safety/

http://www.nris.npsa.nhs.uk/resources/patient%20-safety-topics/medication-safety/




12. APPENDIX 1A - RISK CATEGORISATION OF ERROR/NEAR MISS

Potential for Impact Assessment

Recurrence Negligible Minor Moderate Major Sentinel/Critical

Almost certain. YELLOW YELLOW AMBER RED RED

Likely YELLOW YELLOW AMBER RED RED

Possible GREEN YELLOW AMBER RED RED

Unlikely GREEN GREEN GREEN AMBER RED

Rare GREEN GREEN GREEN AMBER RED

Potential for recurrence: Almost certain = over 95% Likely = 75-95% Possible = 25-75% Unlikely = 5-25% Rare = 0-5%

Management Principles for Category of Error /Near Miss GREEN Ward Manager

• Assess facts, reflect, jointly discuss. (NB if second or subsequent error/near miss; multiple errors involved; deliberate intent; deliberate concealment of error – escalate category (Amber) and conduct RCA (potentially Red). Deliberate intent or concealment must be referred to the Police (Criminal Courts and Justice Act).

• Any incident with a controlled drug must be recorded using Datix.

• Confirm knowledge • Pass on lessons learnt as appropriate

YELLOW Ward Manager / Senior Nurse Manager / Head of Nursing

• Assess facts, reflect, jointly discuss. • Consider temporary restrictions to practice pending initiate training/competence assessment programme. • Review within specified time. • Pass on lessons learnt as appropriate

AMBER Ward Manager / Senior Nurse Manager / Head of Nursing / Nurse Advisor / Workforce &OD

• Assess facts/investigate, reflect and jointly discuss • Temporary restrictions to practice pending initiate training programme and competency assessment

allowing time for achievement.

• Allocate mentor. • Regular reviews. • Capability policy invoked if competencies not met by set date. • Consider formal disciplinary action for all escalated errors/near misses • Lessons learnt devolved Health Board wide

RED Ward Manager/ Senior Nurse / Head of Nursing / Head of Nursing Acute Services / Nurse Advisor MERG /

Workforce and OD team / Assurance Safety and Improvement Manager

• Dependant on circumstance and legal issues. • If left to HDUHB to manage –full Root Cause Analysis investigation • Restrictions to practice pending initiate training programme and competency assessment with detailed

timetable for regular review and achievement.

• Allocate experienced mentor. • Capability policy invoked if competencies not met by set date. • Lessons learnt devolved HDUHB wide

NB – Attend medication safety study day for all principles.



13. APPENDIX 1B- DRUG ERROR DECISION TREE APPENDIX 1B (ADAPTED FROM NPSA GUIDANCE)

No No Yes No Yes Yes No Yes Inform police No Yes No Yes No Yes No Yes Yes No Yes Inform police No

Yes

Yes No No Yes No

Is there evidence that the individual took an

unacceptable risk

DELIBERATE HARM

TEST

ADMINISTRATION OF A NON-

PRESCRIBED

MEDICINE

FAILURE TO

REPORT

FORESIGHT

TEST

SUBSTITUTION

TEST

Did the individual depart from agreed protocols or safe

procedures

Pending police enquires / action

Disciplinary

Were there any deficiencies in training,

experience or supervision

Previous drug error <6/12 months

Were the protocols and safe procedures

available, workable, intelligible, correct and

in routine use

Did the individual fail to report the drug

error

Would another individual coming from the same professional

group, possessing comparable

Qualifications and experience, behave in

the same way in similar circumstances

Supervision or Conduct Discussion or

Disciplinary

Supervision or Conduct Discussion

or Disciplinary

Supervision or Conduct Discussion

or Disciplinary

Re-training File note valid 12 months

Were adverse consequences

intended?

suspension

Were the actions deliberate?

Were there significant mitigating

circumstances

Was the medication in accordance with a

verbal order as directed in trust medication

policy

Start

Here


circumstances


circumstances

Review Policy

RESTRICTED UNTIL APPROVED

[



14. APPENDIX 2 – INCIDENT REVIEW FORM

https://hywelddauniversity.datix.thirdparty.nhs.uk/Live/index.php

https://hywelddauniversity.datix.thirdparty.nhs.uk/Live/index.php




15. APPENDIX 3 - REFLECTION AND LEARNING TEMPLATE

REFLECTIVE ACCOUNTS FORM

You MUST use this form to record your reflective accounts on your CPD and/or practice-related feedback and/or an event or

experience in your practice and how this relates to the Code. Please fill in a page for each of your reflective accounts making

sure you do not include any information that might identify a specific patient, service user or colleague.

Reflective account:

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?

How did you change or improve your practice as a result?

How is this relevant to the Code? Select one or more themes: Prioritise people – Practise effectively – Preserve safety – Promote professionalism and trust.




16. APPENDIX 4 - TEMPLATE TO RECORD DECISION FOLLOWING REVIEW OF ‘INITIAL ASSESSMENT OF FACTS’

Incident Insert brief details

Date of Incident Insert date

Manager undertaking assessment of facts

Insert name of manager and any other support eg Workforce or professional lead

Key points noted Make a file note of the key issues/reasons for reaching this decision. The following are points which you may wish to demonstrate you have considered – the list is not exhaustive.

Facts of the incident

Compliance against Code of (professional) conduct and the professional body guidance pertaining to issue

Compliance with HDHB policy/procedures

Individuals‟ degree of openness / awareness that an „incident‟ had occurred/informing appropriate managers/colleagues.

Individuals‟ actions taken subsequent to incident to ensure patient safety (if applicable)

Degree of systemic vs individual conduct/ performance, non compliance etc (if applicable)

Personal circumstances/context at the time of incident

Intention of individual(s) involved in incident

Involvement in: Any previous similar/related incidents (and if so, compliance with previously agreed actions/outcomes)

Decision Make a note of the decision reached based on the above:

No action

Debrief/feedback to individual

Debrief/action plan/reflective practice/initiation of capability policy

Formal counselling under disciplinary framework

Disciplinary Investigation.

Suspension from duty*

Restricted practice imposed*

* See HDHB All Wales Disciplinary Policy Suspension Tool Kit.




17. APPENDIX 5 - MEDICINES POLICY (ACUTE, MENTAL HEALTH, LEARNING

DISABILITIES AND COMMUNITY SERVICES) 268 - Medicines Policy (Acute, Mental Health, Learning Disabilities and Community Services)

http://howis.wales.nhs.uk/sitesplus/862/opendoc/291060




18. APPENDIX 6 - DRUG ADMINISTRATION ASSESSMENT

Name:__________________________ Hospital_______________ PIN number___________________ Work Place____________

The above nurse has demonstrated a satisfactory knowledge Tick if achieved

Section 1 - Preparation

1 Prepare the drug trolley with all equipment required e.g. water jug. [ ]

2 Ensure adequate hygiene e.g. hands are washed. [ ]

3 Ensure red tabard is worn and the nurse explains the rationale for wearing it and their actions if interrupted.

[ ]

Section 2 - Patient information

1 Gives a clear and concise summary of the patients current condition [ ]

2 Gives a clear and concise summary of the patients plan of care [ ]

3 Explains the action of the medication and where the administered medication fits into the plan of care

[ ]

4 Where possible checks the patients understanding of the medication being administered

[ ]

Section 3 - General Prescription check

1 Checks the prescription provides clear and unequivocal identification of the patient for whom the medicine is intended

[ ]

2 Checks the patient‟s identification in accordance with Health Board Policy

[ ]

3 Checks the prescription is:

a) Legible

b) Indelible

c) Dated

d) Signed

e) Has the prescriber‟s bleep number

f) Annotated by pharmacist

g) Known allergies are recorded and signed.

h) Includes weight if the patient is on a weight related medicine.

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

Section 4 - Medicine Check and Administration




4 Checks the details of the medicine to be administered:

a) Form

b) Strength

c) Dose

d) Timing/frequency

e) Route

f) Expiry date

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

5 The nurse considers the following in the context of the specific patient at that time

a) Dose

b) Route

c) Timing

[ ]

[ ]

[ ]

6

Checks the medication in relation to other prescribed medications to ensure there are no contraindications

[ ]

7 Gains consent prior to the administration of the medicine/s [ ]

8 Administers or assists the patient to take the medication correctly [ ]

9 Is able to identify what effects, reactions or side effects could be observed by the patient following administration.

[ ]

10 Demonstrates a caring and competent attitude throughout the procedure

[ ]

Section 5 - Documentation and Consent

1 Makes a clear, accurate and timely record of the administered medication ensuring it is signed, timed, dated and legible

[ ]

2 Justifies any actions or omissions [ ]

3 Makes clear, accurate and timely record of any medication withheld [ ]

4 Makes a clear accurate and timely record of any patient‟s refusal to accept medication

[ ]

5 Considers the effect of a withheld or refused medication on the patient‟s condition

[ ]

6 Considers the effect of a withheld or refused medication on other medications prescribed

[ ]

7 Acknowledges the patient‟s right to refuse medication [ ]

8 Contacts the prescriber if a refusal occurs [ ]

9 Records any positive or negative effects of the medication and feeds back appropriately to the prescriber

[ ]

Section 6 - Policy and Accountability Tick if

achieved




1 The nurse is able to locate the current Health Board “Medicines Policy”.

[ ]

2 The nurse is aware of when a second nurse is required to check and administer a medication

[ ]

3 The nurse is aware of their accountability as an administering nurse and their accountability as a checking nurse

[ ]

4 The nurse is aware of their accountability when delegating the administration of medications to others, (qualified and non qualified)

[ ]

5 The nurse is aware of the policy for administration against a verbal instruction

[ ]

6 Demonstrates or can the state the correct procedure for the handling and administration of controlled medication.

[ ]

7 States where medicine information can be obtained in the Health Board.

[ ]

8 Can define what constitutes a medication error or near miss and can state the procedure for the management and reporting of an error or near miss

[ ]

Comments and observations of the assessor

I am satisfied that at this time the above named nurse has demonstrated a safe and robust attitude, knowledge, practice in the administration of medicines.

Signature of assessor_______________ Name of assessor____________________ Designation _____________________ Date_____________ Time_____________