Medication Incident Self-Reflection Tool v1.0

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Medication Incident Self-Reflection Tool

Accept that learning means changing / Seek opportunities for learning

Enhancing safe medicines management practice. Thank you for reporting this incident.

The main aim of the tool is to guide you in reflecting upon your practice following any medication
incident. The reflective tool should be completed in a timely manner following the incident to help
guide reflective practice conversations with your manager and it can also be useful during an
appraisal review to support development.

Following the discussion, you and your manager will agree what further actions are required, e.g.
policy/protocol review or any other activities to support your practice.

You will be supported during this process by your manager and/or educator. After completion, this
tool and associated activities may be used as evidence of your continuing professional development
and can be used as evidence for revalidation.

This toolkit should be supported by local performance management processes and used alongside
HCA-UK CORPORATE INCIDENT AND SERIOUS INCIDENT (SI) MANAGEMENT POLICY,
HCAUK.GOV.ALL.POL.1005.

HCA-UK encourages a sensitive response to medication related incidents through a comprehensive


assessment taking full account of the context and circumstances surrounding the incident.

All staff involved in the prescribing, dispensing or administration of medicines must be able to
demonstrate understanding and compliance with relevant professional guidance and HCA-UK
Policies and procedures.

It is the individual staff’s responsibility to ensure they have the relevant knowledge, skills
competences and confidence concerning the prescribing, supplying/dispensing or administration of
medicines.

Immediate actions to be completed within 24 hrs of a medication incident

1. Assess the patient’s condition and take necessary actions to maintain patient stability
2. The incident must be reported immediately to the Line Manager / person in charge and the
patient’s clinicians / consultant
3. Seek advice from Pharmacist / prescriber regarding the possible outcomes of medication
error
4. In the instance of a dispensing incident, inform the Pharmacy and make arrangements for
re-dispensing
5. Complete an incident report form (Datix) and ensure the incident is documented in the
patient’s medical record
6. Escalate as appropriate to the Chief Nursing Officer. It is essential this is carried out
expediently to allow for a timely investigation in the event of a more serious event. In the
event of an incident occurring out of hours the Duty Manager on call should be informed
7. Inform the patient as appropriate (Duty of Candour) after consultation with Line Manager
8. The Accountable Officer for Controlled Drugs (AOCD) (normally CNO), Pharmacy Manager
Head of Governance must be notified of all controlled drugs related incidents
9. If 2 registered clinical staff members are involved in the checking and/or administration of a
medicine, then the medicine incident procedure will apply to both members.
Notice of Confidentiality: The contents of this document are confidential and copyright to HCA
International and may also be privileged.
Definitions of medication related incidents

For the purpose of this document:

• Incidents resulting in harm is an incident or omission arising during clinical care causing
physical or psychological injury to a patient.
• Incidents with significant potential to harm is an incident or omission arising during clinical
care with the potential to cause significant physical or psychological injury to a patient.
• Incidents with potential to harm is an incident or omission arising during clinical care with
the potential to cause physical or psychological injury to a patient.
• Incidents with potential to harm is a medication incident that will not have caused harm but
will be judged to have the potential to cause harm (near miss).
• Incidents with no potential to harm is an incident during the process of procuring,
dispensing, preparing, administering or monitoring which was prevented and would not
have the potential to cause harm.
• Incidents resulting in harm is an incident during the process of procuring, dispensing,
preparing, administering or monitoring which was not prevented and resulted in harm

All medication omissions must be reported.

Examples of scenarios where medication incidents occur (note this is not an exhaustive list):

Prescribing

• Patient prescribed the wrong medication / dose / route / rate


• Medication prescribed to the wrong patient
• Transcription errors
• Prescribing without taking into account the patients’ clinical condition
• Prescribing without taking into account patients’ clinical parameters e.g. weight
• Prescription not signed
• Deviation from HCA Medicines Management Policy or criteria within the Patient Group
Directive (PGD).

Dispensing / Supply

• Patient dispensed / supplied the wrong medication / dose / route


• Medication dispensed / supplied to the wrong patient
• Patient dispensed / supplied an out of date medicine
• Medication is labelled incorrectly
• Deviation from HCA Medicines Management Policy or criteria within the Patient Group Directive
(PGD).

Preparation and Administration

• Patient administered the wrong medication / dose / route


• Patient administered an out of date medicine
• Medication administered to the wrong patient
• Medication omitted without a clinical rationale
Notice of Confidentiality: The contents of this document are confidential and copyright to HCA
International and may also be privileged.
• Medication incorrectly prepared
• Incorrect infusion rate
• Medication administered late / early* *(HCA recognises this is a complex issue and the full
context of late/early administration should be taken into account, however where it would
have a significantly detrimental effect on patient care, this would constitute an error)
Deviation from LCHS Medicines Management Policy or Patient Group Directive (PGD)
criteria.

Monitoring

• Patient allergic/sensitive to medication but the medication was prescribed and/or dispensed
and/or administered
• Failure to provide the patient with correct information regarding their medication e.g. when
to take, what it is for, side effects and drug interactions
• Failure to monitor therapeutic levels
• Failure to undertake appropriate review
• Failure to monitor patient / carer who is undertaking self-medication
• Deviation from HCA Medicines Management Policy or Patient Group Directive (PGD)criteria

Support for staff throughout the medication incident process is available from (not a definitive list):

• Line Manager
• Medicine Management Team
• Chief Nursing Officer
• Quality and Governance Team
• Learning Academy
• Occupational Health
• Professional Bodies
• HR Colleagues

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA
International and may also be privileged.
Name Role: Datix ID:

Date: Signature:

Department: Hospital/Clinic:

Description
What type of medication incident was made? (tick which apply)
 Wrong drug  Wrong patient  Wrong Dose  Wrong time  Wrong route  Omission  Relating to controlled drugs

 Wrong IV rate  Documentation  Delayed dose < I hr from prescribed time  Departure from HCA Medication Policy  Other

If Other Specify?

Name of the drug that was incorrectly administered/ Omitted?

Route of administration: Dose:

Mode of action

Indications for this medication

Have I been involved in a medication incident before? Yes / No (circle) When? Date --/--/--

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA International and may also be privileged.
Evaluation
How and when did I become aware a medication incident had occurred?
When? By Whom?
Immediate Self-Awareness
Delayed Alerted by Patient
Delayed- same shift Another Nurse
After completion of shift Another Nurse/Doctor
Pharmacist
Why do you think this happened?

Feelings?
How did you feel when realised that a medication incident had occurred?

Analysis
Outline potential complications of this medication incident?

Upon reflection, how serious do I believe this medication incident to be?


Add your comments: The situation surrounding the event:
 Minimal

 Minor
Human performance issues: (i.e fatigue, culture, layout, design, behaviour, decisions)
 Moderate

 Serious

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA International and may also be privileged.
Highlight any systems failures identified?

Significant mitigating circumstances?

Reflection
Write a reflective account of the events leading up to, during and after the incident

Reflecting on the incident


What was I trying to achieve?
Why did I act as I did?
What internal/external factors influenced my decision making or actions?
What sources of knowledge (reference HCA policies and NMC Code and HCA Competencies) did or should have influenced my decision-making
actions?
What were my feelings at the time?
What are my feelings now? Are there differences? Why?
What were the effects of what I did or did not do? What ‘good’ emerged from the situation e.g. self/others?
What troubles me now (if anything)?
What would I have done differently/better?
Learning (write your learning points here with an action plan of what you need to concentrate on or do differently as a result)

What did I learn from this experience?

Looking to the future:


What needs to happen to alter the situation?
What are you going to do about the situation?
What happens if you decide not to alter anything?

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA International and may also be privileged.
What information do you need to face a similar situation again?
What are your best ways of getting further information about the situation should it arise again?
Have I taken effective action to support myself and others as a result of this experience?
Identify anything that may hinder your action plans and how you can tackle these?

Pledges I will make: I will stop……………………. I will continue…………………………… I will start…………………………

Learning need Actions to address learning needs Progress and review date

Conclusion
What changes could you make to ensure that the risk of this happening again would be minimised?

OR

Have you changed anything or done things differently as a result of this?

If you plan to use this reflection as evidence in your continuing professional development for revalidation, how does this relate to NMC Code?
Select one or more themes: Prioritising people – Practice effectively – Preserve safety - Promote professionalism and trust

Do you need any support from your Line Manager or Organisation?

Would you be open to share this experience so others can learn from it? Y / N (circle) - Encourage widespread change in practice.

Key Medicine Safety Message?

Managers Comments:

Staff Name: Signature: Date:


Managers Name: Signature: Date:

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA International and may also be privileged.
This document to be read in conjunction with the corporate policies below: -

Policy: HCAI CODE OF PRACTICE FOR CONTROLLED DRUGS Policy Number:


HCAUK.PHA.ALL.POL.1001

Policy: HCAI CORPORATE MEDICINES MANAGEMENT MANUAL Policy Number: -


HCAUK.PHA.ALL.POL.1001

Policy: CORPORATE INCIDENT AND SERIOUS INCIDENT (SI) MANAGEMENT POLICY Policy
Number: - HCAUK.GOV.ALL.POL.1005

Policy: HCAI OPEN COMMUNICATION WITH PATIENTS (INCLUDING DUTY OF CANDOUR)


Policy Number: - HCAUK.GOV.RM.POL.1003

Learning Academy associated E-Learning Modules

Notice of Confidentiality: The contents of this document are confidential and copyright to HCA
International and may also be privileged.

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