overview of the ordering, storage, prescribing and

Microsoft Word - Overview of the Ordering, Storage, Prescribing and Administration of Medicines for Practitioners of Gateshead Overview of the Ordering, Storage, Prescribing and Administration of Medicines for Practitioners of Gateshead Health NHS Foundation Trust v1
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Name of Policy: Overview of the Ordering, Storage, Prescribing and Administration of Medicines for Practitioners of Gateshead Health NHS Foundation Trust
Effective From: 03/10/2012
This policy supersedes all previous issues.
Overview of the Ordering, Storage, Prescribing and Administration of Medicines for Practitioners of Gateshead Health NHS Foundation Trust v1
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by
Medicines Governance
Group
29/08/2012 Format and monitoring changes to meet Trust, CQC and NHSLA
Standards
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Contents Section Page 1 Introduction .................................................................................................... 4 2 Policy scope ................................................................................................... 4 3 Aim of policy ................................................................................................... 4 4 Duties (Roles and responsibilities) ................................................................. 5 5 Definitions ...................................................................................................... 6 6 Main Body of the policy .................................................................................. 8
6.1 Untoward Incidents .............................................................................. 8 6.2 Suspected Misuse of Medicines .......................................................... 8 6.3 Poisoning ............................................................................................. 10 6.4 Drug Supply for Clinical Emergencies/Cardiac Arrest ........................ 10 6.5 Drug Supply in other Clinical Emergency Situations ........................... 10 6.6 Defective or Hazardous Medicines – Reporting ................................... 11 6.7 Controlled Stationery ........................................................................... 12 6.8 Positive Patient Identification & Allergy Status .................................... 12
7 Training .......................................................................................................... 14 8 Equality and diversity ..................................................................................... 14 9 Monitoring compliance with the policy ............................................................ 15 10 Consultation and review ................................................................................ 16 11 Implementation of policy (including raising awareness) ................................. 16 12 References ..................................................................................................... 16 13 Associated documentation (policies) .............................................................. 17 Appendices Appendix 1 Medication Incident Investigation Tool .................................................. 18 Appendix 2 Medicines approved for storage outside locked medicines Cupboard ... 20 Appendix 3 Medication defect report form ................................................................ 21
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OVERVIEW OF THE ORDERING, STORAGE, PRESCRIBING AND ADMINISTRATION OF MEDICINES FOR PRACTITIONERS OF
GATESHEAD HEALTH NHS FOUNDATION TRUST 1 Introduction
The Care Quality Commission (CQC) requires that all acute Trusts establish, document and maintain effective systems to ensure medicines are handled safely and effectively throughout the Trust. This policy aims to outline roles and responsibilities in relation to the ordering, storage and prescribing of medicines across Gateshead Health NHS Foundation Trust and the administration of medicines by Trust staff in all locations. The policy aims to be a working document and sections will be reviewed on a rolling basis through the Medicine Governance Group. In addition it is recognised that it will need to be reviewed in the light of experience or developments. This will be through review of the policy following investigation of serious untoward incidents or identification of regular less serious incidents to ensure adequate guidance has been provided. If any member of the nursing, midwifery or health visiting staff cannot adhere to this policy for any reason, it must be brought to the attention of the Director of Nursing and Midwifery in writing. If medical prescribers cannot adhere to this policy for any reason, it must be brought to the attention of the Medical Director in writing. If pharmacists or any other Healthcare professionals cannot adhere to this policy for any reason, it must be brought to the attention of the Pharmacy Service Manager in writing. Any comments/suggestions about this policy or amendments required as part of a development should be made in writing to the Medicine Governance Group.
2 Policy scope
This Policy applies to all staff employed by Gateshead Health Foundation Trust involved in any aspect of the management of medicines. All staff must familiarise themselves with the procedures contained with the suite of medicine management policies (MM01-MM06). The policy has been developed within the context of the documents identified in section 12: References.
3 Aim of policy
To promote the safe and effective management of medicines across Gateshead Health NHS Foundation Trust
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4 Duties - roles and responsibilities
Trust Board To ensure there is a safe and effective medicine management system that meets the requirements of the Care Quality Commission Executive Director The Medical Director is the executive lead for the safety of medicines across the Trust. Divisional Managers and Divisional Directors The Divisional managers and Directors are responsible for ensuring that their staff, particularly new starters and locums, follow the procedures within this document, which may differ significantly from elsewhere they may have worked. Heads of Department /Assistant Divisional Managers Heads of Department are responsible for ensuring that their staff, particularly new starters and locums, follow the procedures within this document, which may differ significantly from elsewhere they may have worked. All staff All staff in the Trust who manage or handle medicines must familiarise themselves with this document and attend training updates so that they maintain their skills and are familiar with procedures. All staff should ensure any documentation pertaining to medicines should be accurate, comprehensive and legible and stored securely in line with local guidance. It is the responsibility of all staff to ensure they are competent to carry out specific medicines handling tasks relevant to their role. Responsibilities of the Nurse/ Midwife The sister/charge nurse is accountable for the safe custody and administration of medicines kept on the ward/department and for ensuring that stocks of controlled drugs, if held, are safe and secure and correspond with the details shown in the register. The nurse caring for the individual patient is responsible for liaising with pharmacy to ensure the timely supply, safe storage and administration of all medicines required. In addition the nurse in charge of each ward/department is jointly responsible with pharmacy staff to agree which medicines are held as permanent ward stock. Responsibilities of the Pharmacy Service Pharmacy staff are responsible for the safe & effective procurement of all medicines to be used in the Trust. Pharmacy staff are responsible for the stock of medicines held in the pharmacy and that there is a supply and distribution process in place which ensures medicines are provided in a safe, accurate and timely manner. Dispensing processes are managed through a range of standard operating procedures held within the pharmacy department. The Chief Technician and the
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Pharmacy Operational Services manager are jointly responsible for ensuring these reflect best practice and are kept up to date. It is the responsibility of Pharmacy staff to provide evaluated, independent information and advice to patients and health care professionals, and to monitor and evaluate prescriptions for appropriateness of prescribing. Pharmacy staff oversee the safe, effective and economic use of medicines across the trust. This process includes regular monitor of prescriptions to ensure appropriateness, accuracy, safety and clarity of prescribing. This is further described in MM04, Pharmacy Standards for chart annotation. Responsibilities of Prescribers: Medical and Non-medical Prescribers Medical staff are responsible for the majority of prescribing of medicines for patients. They and other authorised prescribers must adhere to the standards described in MM04. Prescribers must sign all prescriptions for medicines and it is essential that the identity of the prescriber is known. Prescribers should print their name and/or professional registration pin number on all prescriptions for this purpose. Non-compliance with the prescribing policy will be reported to the clinical lead and discussed at the multi-disciplinary team meeting. Responsibilities of Other Registered Healthcare Staff. Some other healthcare staff may be involved in the medicine supply and administration processes. The healthcare professional will be authorised to undertake a specific role and will do so in accordance with the directions of a prescriber, prescription or patient group direction and follow appropriate training and assessment, e.g. radiographers, operating department assistants. Access to medicines and responsibilities for medicine stocks must be clearly defined in all clinical areas and be in line with the requirements of medicines legislation. Portering Staff Portering staff are responsible for the safe and timely delivery of medicines from the pharmacy to the wards, departments and clinics. The roles and responsibilities of more explicit duties are described in each policy MM02-MM06
5 Definitions
For the purpose of this document the following definitions apply: The Trust refers to Gateshead Health NHS Foundation Trust. The Patient refers to a patient in hospital, in their own home, health centre, attending a clinic, in school, GP surgery or an employee attending the occupational health department who is under the care of the Trust. Medicine/Medication is defined as any substance, internal or external, used for thetherapeutic, diagnostic or preventative purposes in the above settings.
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Nurse is defined as a registered nurse or midwife whose name appears on the appropriate part of the Register and reflects the area in which they are practicing. They will have a valid NMC Pin Number Nurse preceptee is defined as a newly registered practitioner, who with support by a preceptor, is undergoing a period of structured support during which he or she will develop confidence as an autonomous practitioner, refine skills, values and behaviours and continue on their journey of life long learning. During this period the preceptee will not administer medicines unsupervised until satisfactory completion of their drugs assessment. Throughout this policy where there is an identified requirement for two qualified nurses, one must have completed a drugs assessment. A preceptee who has NOT completed their drugs assessment should only be used as the second checker in exceptional circumstances, and only if the first nurse is confident that they are competent to carry out the checking procedure. Medical Practitioner is a provisionally or fully registered medical or dental practitioner. ODP is defined as an Operating Department Practitioner who has completed a 2 year training programme to achieve a Dip HE in Operating Department Practice (previously NVQL3) Pharmacist is defined as a person registered with the General Pharmaceutical Council. Pharmacy Technicians is defined as a person working in pharmacy with Level 3 NVQ or (BTec) or equivalent and Registered with the General Pharmaceutical Council Anaesthetic Practitioner is defined as a non-medical anaesthetist, trained to UK qualifications, working under the supervision of a consultant ie not an independent practitioner. Administration To give a medicine either by introduction into the body, whether by direct contact with the body or not ( eg orally or by injection), or by external application eg application of an impregnated dressing. Prescribed To authorise in writing the supply and or administration of a medicine. Supply To supply a medicine to a patient/carer for administration Dispense To prepare a clinically appropriate medicine for a patient for self administration, or administration by another. The act of dispensing includes supply and also encompasses a number of other cognitive and practical functions (e.g checking the validity of the prescription, the appropriateness of the medicine for an individual patient, assembly of the product). These functions are usually performed under the supervision of a pharmacist.
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6 Overview of the Ordering, Storage, Prescribing and Administration of
Medicines for Practitioners of Gateshead Health NHS Foundation Trust
6.1 UNTOWARD INCIDENTS
6.1.1 Errors and near misses in drug administration, dispensing or prescribing must be reported to the line manager immediately and a clinical incident reported on line using the Trust Datix system.
6.1.2 To support the future investigation of incidents
• It is essential that staff involved in the incident are noted on the
Datix form as a contact.
• An investigation tool see appendix 1 is available to use.
6.1.3 The patient’s consultant (in the case of hospital patients) or GP (in the case of community patients) must be informed immediately.
6.1.4 The decision to notify the patient/family should be lead by the
medical team.
6.1.5 Recording and reporting of drug errors is encouraged as part of the risk management element of Clinical Governance to subsequently improve practice, learn lessons from mistakes and identify training needs.
This should follow the Trust Policy RM4 Individual incidents must be fully investigated by staff responsible in the areas where they occur. The Pharmacy Clinical Services Manager is responsible for the collation of medication errors reported Trust-wide and identification of issues which need further investigation and action by a multi-disciplinary team. A quarterly report will be produced summarising all the incidents received, and any investigations and action. This person is responsible for the collation of medication errors reported Trust-wide and identification of issues which need further investigation and action by a multidisciplinary team. A bi-monthly report will be produced summarising all the incidents received, and any investigations and action undertaken as a result of this work will be overseen by the Medicine Governance Group.
6.2 SUSPECTED MISUSE OF MEDICINES
6.2.1 Action to be taken:-
6.2.1.1 Anyone discovering an apparent loss of any medicines,
controlled drugs or otherwise, must report their suspicions directly to the ward manager or deputy and the pharmacy service manager or deputy. This must be done immediately any concerns are identified. When the pharmacy is closed,
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6.2.1.2 The ward manager or deputy will immediately inform the
service manager/clinical leader and commence a detailed investigation into the apparent loss.
6.2.1.3 The Divisional Manager or an Assistant Divisional Manager
will liaise with the pharmacy service manager to agree the potential severity of the incident and whether and what stage a Trust Director, Risk Management staff and/or Human Resources personnel need to be informed.
6.2.2 Investigation:-
6.2.2.1 A thorough examination of recording and checking
procedures will be undertaken by the appointed nurse in charge and Divisional Manager or an Assistant Divisional Manager /clinical leader to establish any numerical error or confirm the suspicion of loss.
6.2.2.2 Consultation will involve a hospital pharmacist, identified by
the pharmacy services manager to establish/confirm any numerical error or confirm the suspicion of loss.
6.2.2.3 The incident must be reported through the datix system to
ensure trends in losses of medicines can be collated.
6.2.2.4 For individual incidents as serious in 6.2 or where a trend is emerging from retrospective analysis of datix an investigation report must be prepared for review by the relevant Trust Director and or Corporate Risk Management who will decide the necessary further action. This may include informing the police or contacting them for advice.
6.2.2.5 All risks graded as high (15-25) MUST be escalated for
further investigation and consideration given to those with a moderate risk rating (8-12).
6.2.2.6 The Trust Director involved will inform the Chief Executive
of the occurrence as necessary.
6.2.2.7 Subsequent action will be dependent on the outcome of the investigation.
6.2.2.8 Review of the number of suspected misuse of drugs
incidents will be a key component in the overall monitoring of the effectiveness of Trust procedures for the safe and secure handling of medicines.
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6.3 POISONING
Routine requested for medicine information should be channelled through the pharmacy department. In cases of POISONING when a pharmacist cannot be contacted quickly and information is needed urgently, outside normal pharmacy hours, then a direct approach may be made to: NATIONAL POISIONS INFORMATION SERVICE Telephone: 0870 6006266
6.4 DRUG SUPPLY FOR CLINICAL EMERGENCIES/CARDIAC ARREST
6.4.1 Agreed emergency boxes are provided by the Pharmacy Department
for use in wards & departments and are for use in emergency situations only.
6.4.2 These boxes are supplied with a tamper evident seal and MUST be
stored in the designated location on the resuscitation trolley.
6.4.3 Once the seal has been broken the box must be returned to the pharmacy department and a new one will be supplied.
6.4.4 A record of expiry date is retained in pharmacy. On site wards will be
issued with replacement boxes before this date. Wards or departments remote hospitals should telephone for a new box and the old box returned only when the new box has arrived.
6.4.5 No additions or replenishment to these boxes must be carried out on
the ward.
6.4.6 Monitoring of complete, in date emergency boxes is undertaken as part of the Trust wide audit of resuscitation trolleys.
6.5. DRUG SUPPLY IN OTHER CLINICAL EMERGENCY SITUATIONS
6.5.1 Medicines should be stored at a level of security appropriate to their
proposed use and at a level appropriate to the staff present at any time.
6.5.2 For the majority of medicines this will be the locked ward drug
cupboard, medicines trolley or patient’s bedside locked medicine cabinet.
6.5.3 Practitioners identifying other clinical emergencies where an urgent
source of medicine, to be stored in an unlocked receptacle, is required must make written application to the Medicines Governance Group . This will ensure a standard approach across the Trust and effective risk benefit analysis of the situation and a record of other drugs classified as required for use in an emergency to be maintained.
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6.5.4 Approved drugs to be stored outside locked cupboards are listed at Appendix 2.
6.6 DEFECTIVE OR HAZARDOUS MEDICINES – REPORTING
6.6.1 Any incident or observation which occurs on inspection or administration of a medicine which could be due to a defective product should be reported to the Doctor managing the patient’s care and to the Pharmacy. It may be difficult to distinguish between a defect and adverse drug reaction and the advice of a Pharmacist should be sought if necessary. If the suspected defect has been identified prior to administration to a patient then no doses from that batch should be administered – unless it is a life threatening emergency and no alternative is available.
6.6.2 Defect Classification
6.6.2.1 Major Defects
This is a defect that represents a definite risk to patients if its use is continued. In this event the incident must be reported to a pharmacist immediately it occurs. The switchboard should be requested to contact a pharmacist outside pharmacy opening hours. The pharmacist will require the name of the medicine, the details of the incident, the batch number and the manufacturer. The pharmacist will make arrangements for withdrawal of the product and informing the DH Medicines Division after consultation. A suitable pro-forma for recording this information is at Appendix 3. Where patients have been harmed eg prolonged stay in hospital/permanent harm/death, the incident MUST also be reported on a DATIX form AND the Trust’s Serious Untoward incident process initiated.
6.6.2.2 Minor Defects These are defects in packaging or presentation that are not in themselves a hazard. They must be reported to the pharmacist as soon as the pharmacy reopens.
6.6.2.3 If the classification of a defect is in doubt the advice of the pharmacist should be sought.
6.6.2.4 Manufacturer’s Drug Recalls
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6.6.2.5 Incoming notification of defective medicines will be dealt with by the pharmacy according to Regional procedures.
6.6.2.6 Major defects will be dealt with immediately by informing all
users of the defective product and batch numbers by telephone. As soon as the call is received stocks must be checked. Any batches that wards have in stock must be placed in a sealed bag or envelope and clearly marked ‘Defective Drugs: Do Not Use’.
The Pharmacy department will arrange for collection of the defective products as soon as possible.
6.6.2.7 Minor defects will be dealt with by withdrawal of the items
as soon as practicable.
6.7 CONTROLLED STATIONERY The following items are treated as controlled stationery and MUST be ordered using the Controlled Stationery Order Book provided by pharmacy :- All prescription forms for discharge and outpatients Temporary Stock Order Books Controlled Drug Order Books and Registers Patient’s Own Controlled Drug Registers Potassium Order Books Controlled Stationery Order Book FP10HPs Non medical prescribing pads The pharmacy department will maintain a record of all Controlled stationery issues
6.8 POSITIVE PATIENT IDENTIFICATION AND ALLERGY STATUS.
6.8.1 It is imperative that the identify of the patient is correctly confirmed and any allergies are known.
6.8.2 The correct method of positive patient identification is described in
RM40. All in-patients must have a printed ID wristband produced using the PAS system. The only exception are new born babies which will change when a printed alternative is available.
6.8.3 Before any medicine is either prescribed, administered or a named
patient supply initiated a positive patient identity must be confirmed. Generally speaking, the patient knows better than anyone who they are, where ever possible ask the patient to confirm their identity.
ASK the patient for their full name and date of birth. NEVER ask the patient ”are you” Mr/Mrs Jones” as the patient may have misheard you and mistakenly agree.
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ALWAYS check the patients verbal reply against prescription sheet AND the patient’s ID wristband, which must say exactly the same. Never assume a minor difference is not important. Patients can have very similar names and dates of birth.
NEVER assume the patient is in the right bed as the name above it suggests. The patient may be sat on the wrong bed, the board above the bed may not have been updated or the drug chart may have been put back on the wrong bed end.
6.8.3 It is a mandatory requirement that the documented allergy status of
patients is available at the point of drug prescribing, administration or named patient supply and must always be verbally confirmed immediately prior to any of these actions.
6.8.4 Nurses, midwives and pharmacists are authorised to complete the
allergy box of the prescription chart. This is not solely the responsibility of medical staff. The date and identity of the person completing the allergy box must be stated. The nature of the allergy/intolerance should be crosschecked from two sources wherever possible. This can include:-
Patient Patient’s hospital notes Patient’s next of kin GP referral letter. Direct contact with GP.
6.8.5 It is NEVER acceptable to leave the allergy box blank. The
Kardex must be marked with either of the following:
The specific medication or substance to which the patient is known to be allergic/intolerant must be documented clearly.
No Known Allergies - suitable documentation if the patient is able to confirm
Unknown - only suitable in situations in which it is not possible to verify the allergy status of the patient.
6.8.6 In order to distinguish between serious allergy and less harmful drug
intolerance, the symptoms of any reported allergy must be documented. E.g. mild skin rash, GI disturbance, anaphylactic shock. If a patient experiences a new or different reaction during a later episode of care the medical record MUST be updated to reflect the most recent allergy status
6.8.7 PHARMACOLOGY OF THE MEDICATION. All staff must make themselves aware of the medications they are prescribing and administering to patients with allergies including knowledge of the pharmacology of the medication.
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6.8.8 Errors have occurred even when the allergy status of a patient has been clearly documented, because both the prescriber and the person administering the medicine were unaware of the constituent products. This is particularly the case for penicillins where many products have names that do NOT immediately suggest they contain a penicillin.
6.8.9 There is currently no requirement for manufacturer’s drug labels to
include the warning “CONTAINS A PENICILLIN”. Orally dispensed drugs for an individual patient by the Trust pharmacy will carry this supplementary label but this facility is not available on I V or oral products held as ward stock.
6.8.10 Approximately 10% of penicillin- sensitive patients may also be
allergic to cephalosporins and other beta-lactam antibiotics, which are structurally similar to the penicillins.
6.8.11 The list of current formulary Penicillins & Cephalosporins is available
on the medicines Information site of the Trust intranet.
7.0 Medicine Management Training
Medicines management is continuously a key focus of the NHS Litigation Authority (NHSLA) and the Care Quality Commission (CQC). Training needs to be available, not only for pharmacy staff but for all staff who handle medicines, from porters through to medical staff. Current Medicines Management Trainnig is included in the Trust’s Mandatory Training Needs Analysis (TNA).
8.0 Equality and Diversity
8.1 The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy aims to promote equality of opportunity and eliminate unlawful discrimination, by enabling staff to take into consideration the needs of individual patients, for example as discussed below:
8.2 It is recognised that sometimes patients have sensory disabilities or
impairments, and sometimes patients cannot speak English or experience other communication difficulties or barriers. In these situations, staff recognise that information obtained and provided from other sources may be valuable.
8.3 Staff may refer to patient passports or other similar tools that are sometimes
available. For example patients with learning difficulties have a hand held personal document “My Health Record” which includes information about their medicines. A resource file is available in all ward areas with other information to support patients with disabilities.
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8.4 The constituents of medication are considered if there is a possibility that they might conflict with religious beliefs but this will be in discussion with individual patients i.e. there is no assumption that a patient will not use a product due to religious beliefs. For example informing a Jehovah’s Witness that immunoglobulin is derived from human blood, explaining to Jewish and Muslim patients that some insulin are derived from pork, telling Hindus that the product recommended contains eggs.
8.5 The ability of patients to administer medicines and any difficulties that the
form of medication might present are considered and suitable alternatives prescribed where available. For example, if somebody is unable to swallow tablets the medication may be prescribed in liquid form. Similarly, the type of packaging the medicine is supplied in will also be considered e.g. the patient may have difficulty opening child-proof bottle tops.
8.6 Prescribers will ensure that they work in agreement with all patients. i.e. that
they understand when and how to take their medication, but special consideration may need to be given for those with learning difficulties or mental health problems. It is also usual practice for staff to ascertain whether women of child bearing age may be pregnant.
9.0 Monitoring compliance with the policy
Standard process /issue
Clinical Pharmacy Services Manager
Medicines Governance Group
CLIPPA/ Safecare Newsletters
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Monitoring of database with preparation of monthly report on outstanding policies
Trust Secretary
Compliance with each stage of the process
An audit of all new and revised policies during the year
Trust Secretary
PQRS Annual
10.0 Consultation and review
Members of the Medicines Governance Group and the Equality and Diversity Co- ordinator.
11.0 Implementation of policy (including raising awareness)
All members of staff will be informed via e-mail and the Medicines Management Newsletter as and when the policy is reviewed and re-implemented.
12.0 References
• Medicine Act 1968 • Misuse of Drugs Act 1971 • Misuse of Drugs Regulations 2001 • Misuse of Drugs Safe Custody Regulations1973 • Health Act 2006 • Equality Act 2010 • Controlled Drug (Supervision of Management and Use) Regulations 2006 • Safer Management of Controlled Drugs: a guide to good practice in
secondary care (England) 2007 • The Government’s response to the Shipman Inquiry’s Fourth Report • The Duthie Report – Guidelines for the Safe and Secure Handling of
Medicines (March 2005 revision The Safe and Secure Handling of medicines: A Team approach RPSGB
• NMC Standards of Conduct, Performance and Ethics for Nurses and Midwives
• NMC Standards for Medicines Management • NMC Midwives Rules & Standards • NMC Standards for proficiency for Nurse and Midwife Prescribers • The Royal Pharmaceutical Society of Great Britain Current Medicines, Ethics
and Practice. A Guide to Pharmacists. • Crown Report – Review of Prescribing, Supply and Administration of • Medicines 1998 • The Best Medicine - Health Care Commission 2007 • British National Formulary,, BMJ Group & RPS Publishing, UK • A Spoonful of Sugar: Medicines Management in NHS Hospitals. • Audit Commission 2001
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• Building a Safer NHS for Patients – improving medication safety (DH 2004) • NHS Litigation Authority • An Organisation with a Memory (DoH, 2000) • Technical patient safety solutions for medicines reconciliation on admission
of adults to hospital. National Institute for Health and Clinical Excellence (NICE) in collaboration with the National Patient Safety Agency (NPSA). December 2007
• Medicines Reconciliation: A Guide to Implementation. National Prescribing Centre.2008
• Medicines Management: Everybody’s Business • A guide for service users, carers and health and social care practitioners
(DH,2008) • Medicines Adherence: involving patients in decisions about prescribed
medicines and supporting adherence. NICE Clinical Guideline 76 (2009) • National Prescribing Centre, Mixing of medicines prior to administration in
clinical practice – responding to legislative changes, May 2010 • Department of Health, Mixing of medicines prior to administration in clinical
practice: medical and non-medical prescribing, May 2010 • Thames Valley Y-Site Intravenous Drugs Compatibility Chart (March 2011),
Thames Valley critical care network pharmacists group • Palliative care Formulary • The Syringe Driver: Continuous Subcutaneous Infusions in Palliative Care • National Cancer Peer Review Programme – Chemotherapy Measures • Updated national guidance on the safe administration of intrathecal
chemotherapy • NCEPOD Systemic Anti-Cancer Therapy: For better, for worse? (2008) • NCAG Chemotherapy Services in England: Ensuring quality and safety
(2009)
13.0 Associated Documentation MM02: Ordering, Supply, Transport and Storage of Medication Policy MM03: Medicines Administration Policy MM04: Prescribing Policy MM05: Safer Management of Controlled Drugs Policy MM06: Anticancer Medicines Policy RM04: Incident Reporting and Investigation Policy RM40 Positive patient identification.
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Was there an error with the medication?
Is this due to an individual? Were there
environmental issues?
Protocol not followed Guideline not followed Procedure not followed Incorrect equipment set up
Patient absent from ward Medication unavailable Route inappropriate No signature Wrong dose Wrong patient Wrong drug Wrong time Wrong route
Competency Knowledge Understanding Training Lapse of Concentration Intentional deviation from policy
Investigation Tool for Medication Error Please use this checklist to undertake a systematic review of the error. It will help pinpoint where
things went wrong and enable you to identify areas for action/improvement.
Noise Distractions Interruptions Staffing Levels Skill Mix
Yes Yes Yes
Appendix 1
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APPENDIX 3
GATESHEAD HEALTH NHS FOUNDATION TRUST MEDICINAL PRODUCT DEFECT REPORTING FORM a) Date: Time: b) Informant Name: Status:
Ward & Hospital: Telephone No:
c) Description of Product

overview of the ordering, storage, prescribing and

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