Medication errors

Mismanagement/misadministration/misuse of drugs.

Non-reportable concerns

Lower-level concern where the criteria for a safeguarding enquiry is unlikely to be met. However, an internal written record of what happened and what action was taken should be kept. Where there are several low-level concerns, consideration should be given as to whether the criteria may be met for a safeguarding enquiry due to increased risk.

In these cases, it is important that you consider alternative actions to contacting the local authority. These include:

• Review of relevant policies and procedures.
• Internal relevant training provided.
• Review of existing care plans or creation of new care plans/risk assessments.
• Complaints or disciplinary processes.

Examples of non-reportable concerns include:

• Incidents where the person is accidently given the wrong medication, given too much or too little medication or given it at the wrong time but there has been no impact.
• Incidents where there is no impact but that has not been reported by staff members.
• Prescribing or dispensing error by GP, pharmacist or other medical professional resulting in no impact.

Concerns requiring consultation

Incidents at this level should be recorded, and internal policies and procedures followed. Consultation should be undertaken internally as well as through the Sussex Safeguarding Adults Policy and Procedures. Action should be taken to reduce risk and consultation with the local authority Adult Social Care department considered. Following this you may be requested to formally raise a safeguarding concern.

In these cases, it is important that you consider alternative or additional actions to contacting the local authority. These include:

• Share information with CQC and/or the ICB Quality Team or ICB Medication Optimisation for Care Homes (MOCH) team.
• DATIX, serious Incident or alternative review or investigative process.
• Discussion with the GP/Pharmacy.

Examples of concerns requiring consultation include:

• Recurring prescribing, dispensing or administration errors that affect more than one person and result in harm, or the risk of harm occurring.
• Over-reliance on sedative medication to manage behaviour.
• Covert medication administration without due consideration of consent and capacity, correct recorded decision-making and authorisation.
• Misuse of/over-reliance on sedatives and/or anti-psychotropic medication to control behaviour.

Reportable concerns

Incidents at this level should be formally raised as a safeguarding concern with the local authority Adult Social Care department. Consideration should also be given as to whether the police or other emergency services need to be contacted. Ensure Think Family approach if children or other adults may be impacted.

In these cases, it is important that you consider additional actions to contacting the local authority. These include:

• RAISE SAFEGUARDING CONCERN
• If there is an indication a criminal act has occurred, the police must be consulted.
• Immediate safety plans must be implemented.

Examples of reportable concerns include:

• Any medication error causing harm, where medical attention is required, or where death occurs.
• Deliberate maladministration of medicines (e.g., sedation) or failure to follow proper procedures, including reporting of medication errors.
• Pattern of recurring errors or an incident of deliberate maladministration.
• Deliberate falsification of records or coercive/intimidating behaviour to prevent reporting.
• Insufficient or incorrect medication policies and procedures in place.