- Care providers who are commissioned to provide any medication administration service are responsible for ensuring that people who require this service have their medicines at the times they need them and in a safe way.
- Care providers must have clear procedures in place which include arrangements for reporting adverse events, adverse drug reactions, incidents, errors and near misses relating to medicines.
- These arrangements should encourage local, and where appropriate national, reporting and learning, and promote an open honest culture of safety.
- The registered person must protect adults in their service against the risks of unsafe use and management of medicines. This should be by means of appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines used for the purpose of the regulated activity.
- All medication errors should be reported in line with the care provider’s management of incidents policy as soon as possible after the incident.
Medication errors
Mismanagement/misadministration/misuse of drugs.
- The organisation must have clear procedures for staff detailing how a medication error should be recorded, including specific processes for controlled drugs and reporting mechanisms to the Controlled Drug Accountable Officer (CDAO).
- All medication errors, including near misses, must be recorded. This record must detail the impact of the error, any immediate action taken, and also record the date, time, and names of staff and adults using the service who are involved.
- The error should be reviewed, and an action plan put in place to ensure lessons are learnt and the risk of the error being repeated is reduced. It is also important to review the error in the context of previously recorded errors since a series of similar incidents may meet the criteria for a safeguarding concern to be raised.
- Where there are systemic failings in a provider’s medication management process which lead to repeated medication errors, consideration should be given as to whether a safeguarding enquiry into organisational abuse is warranted.
- If there are cases of medication being mismanaged recklessly or intentionally, such as the misappropriation and misuse of drugs by staff, these should always be reported.
Mistakes are made by people across the process, from the GP to the pharmacist and care staff. Incidents occur where a person is accidentally given someone else’s medication, given too much or too little of their own medication, given a medication that has been stopped, or given it at the wrong time. Most errors do not result in harm, but mistakes can lead to serious and, in some cases, fatal consequences.
Incidents meeting the lower-level criteria should, wherever possible, be addressed at a local level with the individuals and professionals concerned. This should be with the aim of promoting positive relationships and an open culture that addresses the underlying issues. Repeated error-making is also a warning that due care is not being taken, even if none lead to harm.
Please note: Internal online incident reporting processes (such as completing a DATIX for those working within acute health services) should still be completed for monitoring purposes. Where a one-off incident or error made is by an agency worker, the agency should be informed as the agency may hold other information regarding errors made elsewhere by the same person.
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.
In this section
- Overview and background
- Neglect and acts of omission
- Self-neglect
- Physical abuse
- Sexual abuse
- Psychological abuse
- Financial or material abuse
- Organisational abuse
- Discriminatory abuse
- Modern slavery
- Domestic abuse
- Pressure ulcers
- Falls
- Medication errors
- Homelessness
- Incidents between adults in a service