Responding to medication incidents

Medication safety incidents

Organisations should respond to medication safety incidents with compassion and proportion using a system-based approach that focusses on learning and improvement rather than blame. These are the fundamental principles of NHS England’s Patient Safety Incident Response Framework (PSIRF).

Actions required following an incident

Where a medication error 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 where required (see Understanding medication safety policy and frameworks (SPS page)). Patients, family and staff affected by the incident should be supported in line with the principles and guidance endorsed by NHS England.

By undertaking learning responses following incidents, healthcare professionals will be able to understand system factors that contributed to an incident or near miss. They provide an opportunity to introduce changes in practice to reduce the likelihood of recurrence. More information on learning responses can be found in the NHS England Patient safety learning response toolkit.

Steps to take

It is important to undertake the following steps:

• Ascertain whether there is an opportunity for learning and improvement, and whether exploring the incident can generate insight needed to support that endeavour.
• Where organisations are working under PSIRF consider priority areas described in the organisational plan and agree whether a learning response is needed.
• Engage with patients, families and staff affected as described above.
• Nominate and agree a learning response lead.
• Establish a learning response team (where required).
• Gather relevant information or data.
• Visit the site of the incident wherever possible if relevant.
• Compile and review all relevant information or data using a systems-based approach to identify system challenges.
• Consider findings from other learning responses and describe areas for improvement.
• Consider opportunities for shared learning and communication.

Principles to follow

Each medication safety event will be managed differently but some key principles should be followed:

• Individualise the level of response to each incident.
• Respond in a timely manner to ensure information relevant to the incident is as accurate as possible. This ensures 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, including:
  • medication charts
  • patient records and other documentation
  • staffing rosters
  • physical items
• Create a chronology of events to support review processes.
• Visit the area where the incident occurred as this can enable human factors and ergonomics to be taken into consideration.
• Engaging with staff, patients and carers is essential, but requesting statements is not recommended.
• A learning response group should be established for managing more complex incidents.
• Ensure the learning response group supports contributions from relevant professional groups, specialities or care settings. It may be necessary to seek expert opinion from clinical specialities or professional leads.
• Identify areas for improvement.
• Define safety actions to address areas for improvement (see NHS England’s safety action development guide for more information).

Governance

The organisation should ensure a governance structure is in place to provide assurance that recommendations from incident investigations are actioned appropriately and learning is shared.

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