Definition of medicines management Incidents reported How medications errors are reported Actions taken to prevent reoccurrence Role of the Supervisor in relation to

medications errors.

The administration of a medicine is a common but important clinical procedure. It is the manner in which a medicine is administered that determines the outcomes for the patient. Eg: clinical benefit or adverse effect.

The administration of medicines has been demonstrated to encompass many areas for potential error.

In 2013 there were 6 reported medicines incidences.

Most of these were ward related. Most of these were simple mistakes from not

checking prescribed dosage and names of medications properly.

These were reported through IR1’s and investigated accordingly.

Governance. Risk Management Midwife. Ownership. Ward Manager/Team Leader reporting same. Other staff or women themselves. Complaints management.

Risky business – highlights most frequent incidents of medications errors

Wrong dose/wrong strengthOmitted medicineIncorrect drug administeredMedication stored in wrong package

Regular SOM medications audit of controlled drugs

Medication errors highlighted at SOM road shows

Governance management PHA Midwives and Medicines leaflet

NMC standards for Medicines Management 2010

Adherence to Trust policies and guidelines Mentorship support for student midwives

Action plan. ◦ Reflective practice◦ Observed medication administration assessment

tool◦ Medicines Management update through C.E.C.◦ Self assessment of medication knowledge tool◦ Good record keeping.(NMC 2012).

Activity Action 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Check Medicine Medicine available (if not arrange supply)                                        

Name of Medicine                                        

Strength                                        

Form                                        

Expiry Date                                        

Opens one pack at a time                                        

Removes dose (‘non-touch’)                                        

Returns container to trolley or replaces / orders if last dose

                                       

Administration to patient Check patient hasn’t had dose                                        

Check patient’s condition – should medicine be withheld?

                                       

Check patient’s identification                                        

Check patient’s allergies                                        

Take medicines to patient and remain until doses taken

                                       

Interaction with patient person centred                                        

Documentation Make accurate record AFTER administration

                                       

Date & Time                                        

Nurse’s Initials                                        

Record omission using reason code                                        

Prescription Patient Name                                        

Unit Number                                        

Name of Medicine                                        

Dose (within normal limits)                                        

Route                                        

Timing and Frequency (fits with expected time of administration)

                                       

Start date                                        

Signature                                        

Allergies (used to check medicine)                                        

‘Lessons Learnt’. We cannot become complacent We are accountable practitioners Be careful!!!