Practical guidance to support those undertaking medication incident investigations

Actions required following a report

Where a medication incident has reached a patient, action should be taken to ensure the patient’s immediate clinical safety to minimise any further harm. Duty of candour should be completed.  Staff involved in an incident should be identified and supported.

Investigation of incidents enables healthcare professionals to understand what led to an incident or near miss and provides an opportunity to introduce changes in practice to reduce the likelihood of recurrence.

Steps to take

Ascertain whether more information is required to allow for learning.  If there is an opportunity for learning:

  • nominate and agree an investigation lead
  • organise and initiate gathering of information / data
  • visit the site of the incident if required
  • establish an incident investigation group if necessary,
  • compile and review all relevant information / data
  • identify care delivery problems and contributory factors
  • make recommendations and develop an action plan if required.

Principles to follow

  • Individualise the level of response and investigation to each incident.  The response to medication incidents should be adapted where necessary.
  • Investigate the incident in a timely manner to ensure information related to the incident is as accurate as possible, that essential data or evidence is not lost, and individuals involved can recount the events while fresh in memory.
  • Use all available sources that may provide insight into factors contributing to the incident.  These include charts, records and documentation, staffing rosters and physical items, which should all be collated.  A chronology of events often supports review processes.
  • Visit the area where the incident occurred.  This can enable human factors / ergonomics to be taken into consideration.
  • Interviewing staff may elicit more useful information than asking for statements.
  • An incident investigation group should be established for more complex incidents or where a more thorough investigation process is thought to be beneficial.   The membership of this group should ideally include representation from all professional groups, specialities or care settings involved in the incident. It may be necessary to seek expert opinion from clinical specialities or professional leads.
  • Recommendations made from investigations should be SMART (specific, measurable, achievable, realistic and timely) and responsibility for each one should be allocated to appropriate individuals with a specific timeframe.


The organisation should ensure a governance structure to provide assurance that recommendations from incident investigation are actioned appropriately.

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