Policy for Managing and Supporting Staff Following a Medication Error
Policy for Managing and Supporting Staff Following a Medication Error
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Policy for Managing and Supporting Staff Following a
To be read in conjunction with Incident Reporting Policy
Incident Investigation policy Supporting Staff Policy
Complaints Policy Policy on Public Interest Disclosure (Whistleblowing)
Disciplinary Policy Education and Training Policy
Consent to Investigation and Treatment Policy Capability Policy
Stress Policy Medicine Policy
Nursing and Midwifery Guidelines
Ratified by: Quality and Safety Committee
Date ratified: November 2009
Name of originator/author:
Name of responsible committee: Quality and Safety Committee
Date issued for publication: March 2010
Review date: March 2012
Expiry date: November 2012
Target audience: All Staff including agency and temporary staff
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CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Lesley Way Patient Safety Manager Deborah Narburgh Matron with responsibility for Medicines
Management Sue Lunec Head of Pharmacy (Provider Services) Vicky Preece Associate Director of Nursing and Therapies
Circulated to the following individuals for consultation Name Designation Sandra Rote Director of Clinical Development and Lead
Executive Nurse Teresa French Director of Provider Services Richard Stringfellow Head of Corporate Development Sumit Bhaduri Medical Director Finbarr Costigan Medical Director Jane Pugh Deputy Director of Provider Services Tracy Baker Health, Safety and LSMS Manager Karen Hunter Quality and Safety Assurance Manager Jane Freeguard Head of Pharmacy Della Lewis Clinical Governance Team Manager Renata Bozikovova Clinical Governance Co-ordinator Lisa Levy Associate Director of Provider Services Sue Warner Associate Director of Provider Services Marie Mccurry Associate Director of Provider Services Ruth Ward Clinical Manager Janet Austin Clinical Manager Deborah Narburgh Matron GP Unit Kidderminster Maria Wilday Matron Princess of Wales Community Hospita Virginia Snape Matron Tenbury Community Hospital Linda Ingles Matron Malvern Community Hospital Karen Young Matron Pershore Community Hospital Sue Lahiff Matron Evesham Community Hospital Chris Nash Director of Human Resources Helen Carmichael Deputy Director of Human Resources JNCC
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1. INTRODUCTION The PCT’s Provider Services Directorate (The PCT) recognises the importance of supporting staff when they have been involved in a medication error which can present great stress and concern for practitioners and where there is a direct impact on the patient. The PCT acknowledges the need to ensure staff are provided with timely, appropriate support following a medication error. The following procedure aims to;
• outline the support available, should staff require it • sets out the responsibilities of staff who are involved in a medication
error • sets out the responsibility of managers in dealing with medication
2. SCOPE This applies to any member of staff employed by Worcestershire PCT, who administers medication. The PCT recognises the diversity of its staff and undertakes to apply this policy equitably and fairly irrespective of gender, race, age, disability, sexual orientation, religion or belief. In the application of this policy the PCT will recognise its duty to each and every individual employee and will respect their human rights.
3. ROLES AND RESPONSIBILITIES Staff Responsibility The member of staff is responsible for reporting all medication errors including near misses immediately either to their line manager/Team Leaders or the senior nurse on duty. The member of staff must assess the situation and ensure that appropriate action is taken following the incident (Appendix 1) and complete the on-line Sentinel reporting system using the risk matrix (appendix 2) to identify how serious the error was and score appropriately. The member of staff is responsible for following any actions identified as a result of discussions with their manager (as set out in the flow chart in appendix 3) or as a result of the outcome of the investigation. Line Manager/Senior Nurse on Duty The manager has overall responsibility for managing and supporting their staff, and for implementing all aspects of this policy. The line manager if available will provide immediate support and advice. Should the line manager not be available then this role will fall to the most senior nurse on duty. The line manager will follow the procedure outlined in the algorithm at appendix 3
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After a medication error, it is important that there should be an opportunity for the staff member to discuss the incident with their manager as soon as possible after the incident. The purpose of the discussion is to:
• Discuss the incident to enable the member of staff to reflect on the circumstances.
• Allow the member of staff to discuss how they feel and discuss any concerns they may have.
• Examine the details of the incident and identify if there are any gaps in policy and protocols that could prevent another incident/near miss occurring again.
• Identify if there are any training or performance issues with the member of staff
• Determine if the member of staff has made a recent or previous medication errors
The line manager is responsible for identifying staff who continue to make medication errors and support them in line with this policy. 4. PROCESSES Process for managing and supporting staff who make a medication error/near miss The manager and member of staff will develop an action plan depending on the needs identified. If the medication error/near miss is of low/moderate severity the manager in conjunction with the member of staff must follow the algorithm in Appendix 3. If the medication error/near miss is of significant or high severity, the manager must follow the algorithm in Appendix 3 and using the PCT’s investigation policy it is the manager’s responsibility to either carry out an investigation or allocate the investigation to another competent trained member of staff. The manager is responsible for checking the risk evaluation and ensuring the sentinel system is updated in a timely manner. Any areas of concern identified as a result of the investigation must be addressed by the manager. If this is an error of significant or high severity, OR if a repeat or second error made by the member of staff within the last two months, then the manager should refer to the Capability Policy and consider using the incident decision tree (National Patient Safety Agency)(Appendix 4) to determine what type of action is required. Working in line with the algorithm in Appendix 3, the manager may need to make the decision to temporarily suspend the member of staff from undertaking medication administration. In all cases, it is important that the member of staff is supported by their manager during this process and kept informed of any actions that may have to be taken.
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5. PROCESS FOR MONITORING EFFECTIVENESS The effectiveness of the policy will be monitored via the investigation of incidents, complaints and claims. In line with the Incident Reporting and Investigation Policies, any serious incidents will be investigated to determine what action was taken by staff, whether they required any support and how effectively this was provided by the Trust.
6. DISSEMINATION, IMPLEMENTATION AND ACCESS TO THIS DOCUMENT
This Policy will be accessible via the PCT Website. Staff will be made aware of its existence by advertising it in the PCT newsletter and on the Patient Safety web page. When no longer in use this policy will be archived in line with the PCT archiving policy.
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Medication Error – Have you considered?
What are the immediate/potential risks to the patient from the drug given or any potential interactions.
Does the patient require urgent medical review, if so, seek help immediately
ie. 2222 or 999
Is what I have given reversible? Consider emergency drug policy.
Complete observations as indicated eg. BP/Blood Glucose etc
If urgent review not required contact Dr to seek further advice
Are ongoing observations required?
Has the patient/family been informed of the medication
Has the Senior Nurse/Senior Manager
Has error been risk assessed and Clinical Incident Report been completed in line with Trust Policy?
Has all documentation been completed?
eg. patient record
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STEP 2 Likelihood Table (What is the likelihood of the consequence occurring?) STEP 4 Action Required Table
Frequency How often might it/does it happen
Definition Action Required All Very Low, Low and Moderate investigation reports to be completed
within 28 days from the date of the incident
Frequent Is expected to occur again either immediately or within a short period of time (likely to occur most days, weeks or months) It is a persistent issue. No control measures and a constant hazard.
Likely Possibly will recur – might occur at some time (may happen every 2 to 3 months). Poor training, lack of supervision or ineffective control in place
Immediate Action Required. Report immediately as a Serious Untoward Incident (SUI) to the On-Call Manager in absence of the Patient Safety Manager (Clinical) or H & S/Security Manager (Corporate) A Root Cause Analysis must be undertaken. Develop, implement and monitor further action plans Submit Investigation Reports to the relevant Director and Risk Management Team
Might happen or recur occasionally. Will probably happen/recur but it is not a persisting issue. Poor supervision or ineffective controls in place.
Need to notify senior management and Risk Management Team. Detailed investigation required. E.g. Timeline. Develop, implement and monitor further action plans; who will be responsible for implementation and the time-scale involved.
Possibly will recur – could occur at some time in 2 to 5 years. Defined safe systems of work are in place with only occasional exposure.
Investigated by the local manager/supervisor/ team leader responsible for the individual involved or the area in which the incident occurred. Exception– all financial losses must be reported to senior management and to the H&S/Security Manager.
Unlikely to recur – may occur only in exceptional circumstances (may happen every 5 to 30 years). The activity is adequately controlled e.g. effective policy, training, supervision, etc, in place.
Local managers would be expected to monitor trends associated with this grade of incident and identify where causal factors are generic to the service/area and take appropriate action to address any local systems failures. Risks should be managed through existing control measures and assessments kept under review.
STEP 3 Risk Matrix This matrix should be used in conjunction with the Incident Reporting Policy
Serious Major Moderate Minor Minimum
Frequent 25 20 15 10 5 Likely 20 16 12 8 4 Possible 15 12 9 6 3 Unlikely 10 8 6 4 2 LI
Rare 5 4 3 2 1 Every incident assessed should be scored separately for both their actual and potential consequence and outcome. i.e. after practice improvement measures are implemented
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ALGORITHM FOR THE MANAGEMENT OF DRUG ERROR / NEAR MISS FOR STAFF WHO ADMINISTER MEDICATION
Low / Medium Severity (yellow risk)
Significant Severity (orange risk)
High Severity (red risk)
Carry out informal RCA (Root Cause Analysis)
Ask clinical staff involved to reflect on incident and include comments on the Incident Report Form
Consider using NPSA Incident Decision Tree to identify any systems errors as part of the informal RCA
Consider: • Arranging Medicines
Administration Training if clinician/s has made a repeat error/near miss
• Temporary suspension from medicine administration
Inform Senior Manager. Carry out formal RCA
Clinician/s involved complete reflective account to be attached to the Incident Report Form
Use NPSA Incident Decision Tree to identify any systems errors as part of the RCA
• If this is a 2nd medication error within a
2 month period suspend from medicine administration while RCA in progress
• Arrange Medicines Administration Training ASAP
• Supportive discussion with clinician and line manager to include review of the reflective account by clinician/s
• Discussion between the clinician/s and Line Manager/ Senior Nurse dependant on the outcome of the RCA
• Supportive discussion to include reflection by clinician/s
• Confirm if this is a repeat error or near miss by the clinican/s
• Ensure training has been delivered before lifting suspension from medicines administration
• Initiate a period of supervision when suspension has been lifted
Consider: • Suspension from duty Following formal investigation consider: • Initiating Disciplinary Procedure • Capability Policy
Assess error/near miss using risk matrix (see separate chart)
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Equality Impact Assessment Report Template Your Equality Impact Assessment Report should demonstrate what you do (or will do) to make sure that your function/policy is accessible to different people and communities, not just that it can, in theory, be used by anyone.
1. Name of policy or function Policy for Supporting Staff involved in traumatic /stressful incidents, complaints or claims
2. Responsible Manager
Lesley Way, Patient Safety Manager
3. Date EIA completed 4. 28.07.09
5. Description of aims of function/policy
The PCT recognises the importance of supporting staff through these challenging situations and acknowledges the need to ensure staff are provided with timely, appropriate support following the event, as required. The following procedure aims to outline the support available, should staff require it.
6. Brief summary of research and relevant data
7. Methods and outcomes of consultation
8. Results of Initial Screening or Full Equality Impact Assessment
Initial or Full Equality Impact Assessment?
Equality Group Assessment of Impact Race Nil Gender Nil Disability Nil Age Nil Sexual Orientation Nil Religion or Belief Nil Human Rights Nil
9. Decisions and or recommendations (including supporting rationale) 10. Equality action plan (if required)
11. Monitoring and review arrangements (include date of next full review)
Department Health and Safety Directorate Corporate Development Director Richard Stringfellow Report produced by and job title Lesley Way, Patient Safety Manager Date report produced July 2009 Date report published March 2010
3. ROLES AND RESPONSIBILITIES
5. PROCESS FOR MONITORING EFFECTIVENESS
6. DISSEMINATION, IMPLEMENTATION AND ACCESS TO THIS DOCUMENT