10.1 Despite best practice measures a medication administration error or incident may occur, for example incorrect dose administered; medication not given or given more than once; medication administered to the wrong person.
10.2 When an error occurs, staff must immediately seek and follow medical advice from a relevant health professional to prevent or reduce harm to the person concerned, then
- communicate the error to relevant staff on duty and to incoming staff
- advise a line / on call manager as appropriate
- record what happened in the plan and the MAR as appropriate
- complete an incident report and provide it to their line manager
10.3 Incident reports must be completed for all errors, incidents and near misses i.e. when a potential error could have occurred but was averted in time.
10.4 Managers must:
- explain what has happened to the person and their family/carers
- investigate the incident
- advise the council’s Safeguarding team where serious harm has occurred or there are significant concerns about errors
- for regulated services, advise the regulator of any incident which meets the criteria for statutory notification and keep the person, their family or representative informed about the investigation and its outcome
- monitor all medication related incidents and near misses to identify trends and take appropriate action to reduce the potential for future problems, for example by reviewing medication procedures; sharing information with staff; requiring staff to repeat training or have additional training
