Medication Incident Self-Reflection Tool v1.0
Medication Incident Self-Reflection Tool v1.0
Medication Incident Self-Reflection Tool v1.0
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.
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.
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
• 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
Examples of scenarios where medication incidents occur (note this is not an exhaustive list):
Prescribing
Dispensing / Supply
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?
Mode of action
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?
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?
Reflection
Write a reflective account of the events leading up to, during and after the incident
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?
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
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
Would you be open to share this experience so others can learn from it? Y / N (circle) - Encourage widespread change in practice.
Managers Comments:
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: CORPORATE INCIDENT AND SERIOUS INCIDENT (SI) MANAGEMENT POLICY Policy
Number: - HCAUK.GOV.ALL.POL.1005
Notice of Confidentiality: The contents of this document are confidential and copyright to HCA
International and may also be privileged.