Creating safe systems
Well-designed systems and processes are essential to minimise the risk of medication errors and ensure patient safety. This article explores how clinical areas can apply best practice when designing each stage of the medicines management process. Well-designed processes can also prevent treatment delays and minimise the risk of wastage.
Clinical environments are complex and often busy, with staff managing multiple tasks under pressure. Systems and processes should be designed with consideration to human factors, for example reducing distractions, avoiding multitasking, and ensuring workspaces are clean, well-lit and organised. Automation and digital tools can reduce reliance on memory and manual processes, but this does not remove the need for professional diligence and undertaking a self-check at each stage of a process. Further details can be found in our article Preventing errors on the medicine journey (SPS Page).
All processes, including storage and stockholding, ordering, receipt, administration, preparation, labelling and supply, disposal and return, should be underpinned by robust procedures and supported by staff training. Staff should be aware of medicines commonly associated with errors, and of working practices that increase risk.
Verification steps, such as double-checks or independent second checks may add value in certain scenarios, such as high-risk processes. Further details can be found in our article about Understanding when a check adds value to medication processes (SPS Page).
Best practice principles described in this article may apply throughout the period when a clinical area is in use, and in particular when the clinical area:
- is first established, including repurposing of a non-clinical area
- has a change of use or activity
- has significant staff changes
Standards and guidance
The Royal College of Nursing, General Medical Council, Health and Care Professions Council and Royal Pharmaceutical Society set professional standards for individual practice.
Design of a clinical area
Good design promotes safe practice and processes. NHS England’s Health Building Notes (HBN) define standards for safe design of healthcare buildings. The NHSE HBN for clinical and clinical support spaces and NHSE HBN for medicines storage in clinical areas are particularly relevant for prevention of errors with medicines.
Examples of best design practice
- Involve multi-professional input into the design at an early stage.
- Consider the clinical use of the area such as the need for additional intravenous (IV) fluid storage in areas with high usage or emergency planning.
- Walk through medication-related processes with key staff groups to ensure design is practical and efficient.
Storage and stockholding
Safe storage and good stockholding practice minimises the risk of errors, including selection errors, inadvertent use of expired medicines and administration omissions or delays.
The Royal Pharmaceutical Society’s professional guidance on safe and secure handling of medicines provides guidance about safe storage.
Our guidance on Assessment and storage of medicines for self-administration (SPS Page) includes principles of safe storage for use in line with self-administration processes.
Storage locations
When reviewing, managing and improving medicines storage, all locations should be included. Clinical areas may have multiple locations for medicines storage, including patients’ bedsides, fluids rooms, clinic or drug rooms, sluice, drug trollies, and resus trollies.
Use segregation to reduce the risk of mis-selection, for example:
- separate different formulations, routes of administration or strengths of the same product
- separate look-alike and sound-alike products where possible
- store diluents and fluids separately from medicines
Stockholding
Stock levels should be sufficient to ensure timely access to medicines, but overstocking should be avoided. A cluttered environment increases the likelihood of selection errors and wastage.
Stockholding lists should be reviewed and rationalised regularly by a clinical area lead and a pharmacy lead together.
An effective stockholding review:
- uses historical usage data to inform requirements
- ensures optimal stockholding of commonly used and time critical medicines
- minimises the holding of medicines with multiple strengths
- removes medicines that are not required from stock
Consumables and ancillaries
Lack of the correct consumables and ancillaries required for administration of medicines may delay therapy or promote unsafe administration practices. For example, wrong route or dosing errors may occur if the correct type or size of syringe is not available.
Managing stock of consumables and ancillaries in a clinical area is usually delegated to nursing staff or housekeepers. These individuals may not be involved in managing medicines stocks. Ordering may be through central procurement rather than the pharmacy department. Good communication and regular review are required to ensure the stocklists are co-ordinated.
Examples of best storage and stockholding practice
- Ensure regular stockholding reviews.
- Use robotic storage solutions where possible to reduce manual selection errors.
- Always keep medicines in their cartons; for example, do not decant ampoules or blister strips.
- Segregate products to minimise mis-selection.
- Standardise practices across clinical areas within the same organisation.
- Promote a tidy and orderly environment.
- Ensure efficient stock rotation.
- Ensure medicines are stored at the right temperature; further information can be found in our article on Understanding why temperature management is important for medicines storage (SPS Page).
Processes should be reviewed when there is any significant change to clinical practice, for example when new clinical guidelines or medicines are introduced.
Ordering and receipt
Ordering processes must ensure the correct medicine is requested in the correct quantity, pack size, strength, formulation and presentation. This minimises the risk of mis-selection, supports timely access to medicines and promotes efficiency.
Ordering of medicines to a clinical area should only be undertaken by authorised individuals and unauthorised ordering must be prevented.
Failure to order medication in a timely fashion may lead to delayed therapy.
Frequent ordering of stock medications outside of a routine top-up service is an inefficient use of resources and diverts healthcare professionals’ time away from direct patient care.
Examples of best ordering and receipt practice
- Agree maximum stock levels and review regularly.
- Define robust organisational processes, roles and responsibilities for ordering including ‘out of hours supply’, consumables and ancillaries, and Controlled Drugs (CDs).
- Ensure all healthcare professionals within the organisation have suitable training for ordering medicines.
- Use automated storage cabinets that can re-order automatically.
- Use barcode scanning to verify products where possible.
- Allocate staff protected time for timely unpacking and putting away of received medicines.
- Ensure staff know what to do when items received are not what was expected.
Administration and preparation
Healthcare staff need to ensure that the correct medicine is selected, prepared and administered in a safe and timely manner.
Examples of best administration and preparation practice
- Define robust organisational processes, roles and responsibilities for the preparation and administration of medicines.
- Ensure all healthcare professionals have appropriate training.
- Use technology, where possible, to reduce the need for manual checks including barcode scanning, smart pumps and robotic dispensing systems.
- Define contingency processes in the event of disruption to usual services.
- Define self-checking practices and where a second check may add value to high-risk processes.
Labelling and supply
Where medications are authorised to be labelled or supplied within a clinical setting (ward-based dispensing for example), principles of safe handling in pharmacy should be followed. See our article on Managing medicines safely in pharmacy (SPS Page) for more information.
Disposal and return
The return of medicines to pharmacy departments for potential re-use should only be undertaken in line with local policy. Processes for handling returns must be clearly defined, with responsibilities for decision-making and assessment of medicine integrity. Failure to remove these medicines effectively may result in inadvertent selection for another patient, bypassing the processes in place which ensure the medicine is correct and clinically appropriate for the patient.
Safe disposal of medicines that cannot be returned to pharmacy protects the patient, the staff and other visitors to the area. Our article Managing pharmaceutical waste (SPS Page) provides more information.
Examples of best disposal and return practice
- Identify and segregate both pharmaceutical waste and medicines for return to pharmacy. This may include the use of non-access return bins where appropriate.
- Define processes and identify staff responsible for returning medicines to pharmacy to ensure timely and accurate removal.
- Ensure systems are in place for ordering and stockholding of necessary disposal equipment, including sharps and cytotoxic waste bins.
- Ensure all staff are aware of organisational processes for managing pharmaceutical waste.
Associated resources
Resources that should be used alongside this article to support the design of medicines-related processes include: