Medication errors occur even in the best of healthcare environments. Understanding when and how to report them is as important as trying to prevent them in the first place.
What Counts as a Reportable Error
All mistakes with medicines should be reported. This includes errors with dose, patient, time or administration route as well as near misses. Whether or not harm has occurred is also irrelevant. If in doubt whether an incident should be reported, report it and let the manager decide later.
Who to Tell First
Notify the Line Manager or the Senior on Duty as soon as possible after discovery. Inform the affected person or their representative as soon as possible and offer honest and transparent information. The clinical response may need to be delivered quickly.
What to Write Down
When recording, it is important to set out what happened, when it happened and what you did about it. This should be written down in the person’s medication administration record and also recorded in your organisation’s incident log. Any amendments to the initial recording should be clearly marked and include the date and time that the amendment was made.
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When a Safeguarding Referral May Be Needed
If the incident resulted in any form of harm, or there is suspicion that neglect has taken place, a safeguarding referral should also be considered and discussed with the organisation’s safeguarding lead. Under CQC requirements for safe care and treatment, registered providers must report incidents which result in serious harm and/or where medication errors have occurred.
Supporting the Person Who Made the Error
Safe handling of medication also includes how a team handles errors and makes sure that the person who made the error is supported. The debrief should explore what happened and how you can prevent it happening again in future, not look for who was at fault.
Reporting a mistake is an important part of ensuring everyone’s safety and is something that needs to be done promptly and honestly. It is your professional duty to report any errors.
