Version: V5
Ratified by: MGSG
Date ratified:
29.6.2023
Job Title of author: Assistant Clinical Director Pharmacy and Medicines
Reviewed by Sub Group or Expert Group Medicines Governance & Safety Group
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Review Date:
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HRPOL26 Psychological Wellbeing of Staff Policy
QSPOL01 All Incident Reporting (including Serious Incident Reporting) & Management Policy
29.6.2026
It is the responsibility of users to ensure that you are using the most up to date document template – ie obtained via the intranet.
In developing/reviewing these guidelines Provide Community has had regard to the principles of the NHS Constitution.
Version Control Sheet
Version Date Author Status Comment
V1 August 2014 Head of Medicines Management Approved New
V2 November 2016 Head of Medicines Management Review
V3 March2019 Headof Medicines Management Review
V4 August2019 Community Health Specialist Pharmacist Update
V5 May2023 Clinical Lead Pharmacist Review
1. Introduction
Provide recognises the importance of supporting staff when they have been involved in a medication error or a near miss. Such an event can present stress and concern for health practitioners and especially where there is a direct impact on a patient.
The National Patient Safety Agency (NPSA), now part of NICE, published a report in 2009 ‘Tackling medication incidents and increasing patient safety’ in which they reported that the number of medication incidents being reported had increased significantly, indicating that the NHS had improved its reporting culture and was willing to come forward when mistakes have been made, and that the majority of those reported had resulted in no or low harm to patients.
However, the NPSA chief executive stated that ‘millions of medicines are prescribed in the community and in hospitals across England and Wales each day – the majority of these are delivered correctly and do exactly what they are meant to do. However when an incident does occur, it is vital that we learn from this to ensure patients are not harmed’.
The report went on to state that ‘we have learnt from industries such as aviation, that scrupulous reporting and analysis of safety related incidents, particularly ‘near misses’ provides an opportunity to reduce the risk of future incidents. Through the NPSA, the whole of the NHS can learn from the experiences of individual organisations’.
Therefore, Provide has a responsibility to the patients we care for to reduce wherever possible the risk of harm related to medication processes, and Provide needs to encourage reporting of incidents and to ensure all reported incidents are dealt with in a timely, consistent, objective and fair manner.
2. Purpose
This Guidance aims to standardise the management of medication errors or near misses across Provide, and to ensure that staff who are involved in a medication incident are treated objectively, fairly and consistently across all services within the organisation.
This guidance aims to encourage timely reporting of all medication errors or near misses, in order to improve patient safety by identifying and learning the lessons arising from these incidents.
This guidance outlines the responsibilities of staff when involved in a medication error or near miss, the responsibilities of managers when dealing with medication errors or near misses, and sets out the appropriate actions and support necessary for all staff when an error or near miss occurs.
3. Definitions
Patient Safety Incident
The National Reporting and Learning Systems (NRLS) defines a ‘patient safety incident’ (PSI) as, ‘any unintended or unexpected incident, which could have or did lead to harm for one or more patients receiving NHS care.’ (NHS Improvement, 2017)
Medication Error
Medication errors are anyPSIs where there has been an error in the process of prescribing, preparing, dispensing, administering, monitoring or providing advice on medicines. These PSIs can be divided into two categories; errors of commission or errors of omission. The former include, for example, wrong medicine or wrong dose. The latter include, for example, omitted dose or a failure to monitor, such as international normalised ratio for anticoagulant therapy.
Near Miss
This is defined as an event or situation that could have resulted in harm, loss or damage but because of timely intervention, did not actually occur.
4. Scope
This Guidance applies to any health care practitioner who is involved in any stage of the medication process, which will normally include:
• Nursing staff
• Medical staff
• Pharmacy staff
• Allied Health Professionals
• Clinical support staff – where relevant
• Agency or Locum staff
• Administrative staff with responsibility for handling prescribing paperwork and/or clinical/patient notes
5. Responsibilities
Assistant Directors (ADs)
All Assistant Directors must be familiar with this guidance to ensure they understand how the guidance should be applied in practice.
Service Managers
All Managers operationally responsible for service delivery must understand how this guidance should be implemented, and to ensure the staff they have responsibility for are aware of this guidance and how to comply with its content.
Medicines Management Team
In the event of a medication error or near miss, the Medicines Management Team may be approached at any stage for immediate advice and support.
The Medication Safety Officer (MSO) will review each reported medicine incident in a systematic way, and advise on any further action required. Feedback will be provided to the relevant senior managers, as well as to the person reporting the incident, and via the Medicines Governance & Safety Group (MGSG). The Medicines Management Team will offer re-training support as required, for any staff member involved in a medication error or near miss, arising from the error or near miss.
Clinical Managers
It is the responsibility of all clinical managers, e.g. Ward managers, clinical team leads, community matrons, to ensure they understand and apply this guidance in their own clinical area.
Employees
All employees who are involved in the medication process must familiarise themselves with this guidance, so they understand their individual responsibilities and those of Provide.
6. Process to Follow
Provide acknowledges that medication errors or near misses will sometimes happen. What is important is that the organisation and those staff involved in the incident have a clear understanding after the event of the following:
• If there has been any harm done to a patient as a consequence of the incident
• The causal factors that contributed to the incident
• Any potential actions that could have been taken to prevent it happening
• Any training needs arising from the incident
• Whether any staff involved in the current incident have been involved in more than one medication incident over a defined period of time (see Appendix 1)
• If there is an immediate need to address any disciplinary issues arising from the incident
• If there are any Provide processes that need to be reviewed
• If there is any Organisational learning
Provide expects that after each reported medication error or near miss, a thorough investigation should be carried out at local level. The purpose of this investigation is to ensure the points set out above can be answered. This process should be carried out sensitively and any necessary support offered to the staff involved, in line with recommendations made by the NPSA.
However it must be noted that, where incidents are found to involve gross carelessness, repeated errors, criminal, deliberate or malicious actions, action will proceed in line with the Provide Capability or Disciplinary procedures.
Actions to be taken by a member of staff involved in a medication error or near miss
The following action should be taken:
• As soon as the error or near miss is identified, assess the patient’s condition if appropriate, to establish if the patient has suffered any harm
• Discuss and agree who will inform the patient/carer that a medication error has occurred
• Report the incident to the Doctor responsible for the patient’s care
• Document the nature of the incident in the patient’s notes
• Report the incident immediately to the person in charge, and record the error on Datix
• If the error involved a Schedule 2 or 3 Controlled Drug (Sch 2/3CD) then the Accountable Officer (AO), Nisha Desai, needs to be informed within 24 hours and a Datix raised WITHIN 48 hours
Contact Details: Nisha Desai, 07580 911601 Nisha.desai@nhs.net
• If required, seek further advice from a member of the Medicines Management Team
• If the incident involves a dispensing error, inform the relevant pharmacy immediately. The Medicines Management team should also be informed at the same time, so they can also consider the implications of the error
• Consider any further actions necessary following the incident (see Appendix 2)
Actions to be taken by
the senior clinician in charge/
Senior Manager
It is the responsibility of the senior clinician or manager to whom the incident has been reported, to undertake the following actions:
• Follow the ‘Algorithm for the Management of Medication Errors/Near Misses (Appendix 1)
• In the first instance they must:
• Confirm the status of the patient, if relevant, and check if any harm has occurred
• Ensure that all appropriate support has been offered to the member of staff involved in the incident
• Confirm that the Doctor in charge of the patient’s care has been informed
• Confirm that the incident has been reported on Datix
• In following the algorithm, they should ensure that:
• Once the severity of risk has been confirmed, the manager should follow the steps of the algorithm set out in Appendix 1
• An investigation of the incident should be carried out using a Root Cause Analysis (RCA) Template (see Appendix 3), to review the causal factors involved
• At the appropriate time, allow the member(s) of staff involved in the incident to reflect on the circumstances, and identify their own learning
• Identify if there are any training or performance issues with the member(s) of staff, and depending upon the level of risk, take any necessary actions. According to the level of risk identified, this could involve re-assessment of competency or immediate suspension of the member of staff from prescribing, dispensing, preparing or administering medication
Informing the Patient/Carer if a medication administration error has occurred
• It is important for Provide to be open and honest when things go wrong, and therefore it is of great importance that a patient or their carers are informed if a medication error has occurred
• The patient/carer should be informed at an appropriate time by either the nurse or doctor in charge of the patient’s care, and an apology offered This apology should be noted in the patient’s record as per the Duty of Candour processes
• If the error is of a serious nature, following a formal investigation and at the appropriate time, the patient/carer should be offered the opportunity to discuss the outcome of the investigation and to discuss the findings. This provides an opportunity to reassure the patient/carer that Provide is keen to always learn lessons from medication errors, and to prevent similar occurrences in the future
After a medication error/near miss had occurred
After a medication error or near miss has occurred, and all necessary immediate steps have been taken, it is important there should be an opportunity for the staff member(s) to discuss the incidents with their manager, as soon as possible after the incident.
The purpose of this discussion is to:
• Discuss the incident to enable the member of staff to reflect on the circumstances and identify what can be done to prevent future occurrence
• Allow the member of staff to discuss how they feel and discuss any concerns they may have
• Identify if there are any training or performance issues with the member of staff
• Determine if the medication incident is a repeat incident; check if the member of staff has made a previous similar medication error and within what timeframe
• Dependent upon the severity of the error/near miss, to ensure all appropriate support has been offered to the member of staff
• Determine whether the medication incident is a procedural/ system error and policies need to be reviewed accordingly
• If the error occurred due to a Provide process then the organisation can learn from this error to prevent similar errors in the future
A medication error/incident may be a source of concern and stress for employees and it is the line manager’s responsibility to ensure that employees’ mental health issues are understood and where appropriate, supported. Line managers can refer employees to Occupational Health (OH) if an employee exhibits or has potential stress related ill health.
The contact details for OH: Telephone: 0345 643 3468 Email: ang-sa.Occupationalhealth@nhs.net
The Human Resources (HR) department is responsible for leading on all matters relating to the employees of Provide and can help employees resolve any queries and issues they have during their employment. HR focuses on ways to help all employees to perform to the best of their abilities. Refer to Psychological wellbeing of staff policy and procedure (HRPOL26) for information about addressing concerns regarding work related stress or psychological well-being.
Appendix 4 sets out guidance on how to minimise errors from occurring. This highlights some of the problems which may occur in a community setting and identifies solutions on how to reduce the errors.
7. Staff who make Repeat Medication Errors/Near Misses
It is important that all members of staff and their managers comply fully with this guidance, to ensure the organisation is able to manage medication errors and near misses appropriately and particularly to ensure members of staff who make repeat errors/near misses are identified as soon as possible.
By following the Algorithm in Appendix 1, line managers should seek to establish if this is a repeat error or near miss that has occurred within the preceding 3 months.
8. Role of the Medicines Management Team
Medication incidents that are reported via Datix will be reviewed by the Medication Safety Officer. Any incidences relating to Controlled Drugs will be reviewed by the Accounty Officer, Nisha Desai, Assistant Clinical Director Pharmacy and Medicines. The purpose of this review is essentially twofold:
• To establish if appropriate medicines management policies and procedures are in place to support staff in their practice
• To support the process of learning lessons and sharing these lessons with key staff following any medication incident, via the Medicines Governance & Safety Group
• To ensure Provide processes are reviewed by the relevant department
• To determine where Controlled Drug (CD) incidents have been reported need reporting to the Police
(Please refer to QPOL01: All Incident Reporting (including Serious Incident Reporting) & Management Policy for further details on reporting requirements).
9. Training and Competencies
The implementation of this guidance requires that managers are able to carry out a Root Cause Analysis (RCA) into the medication incident where appropriate. The template in Appendix 3 must be used to help identify any learnings and to understand the root cause of the incident, to enable steps to be taken to avoid similar incidents in the future.
The Learning and Development unit should be used to register for any Medicines Management related training needs identified.
