What to do when medication goes wrong

10 common medication errors

There are several reasons why medication can go wrong and the top ten in my experience and according to a poll I conducted, are:

1. Incorrect medication being administered
2. Medication given at the wrong time
3. The wrong dose of medication is administered
4. The medication is given in the wrong route, for example into the ear, instead of the eye
5. The right medication is given but to the wrong person
6. Medication is missed
7. The paperwork isn’t completed, so medication is given twice
8. The paperwork is completed wrong, resulting in staff believing medication has already been administered
9. The pharmacy makes an error with the amount of medication provided
10. Medication is refused, spat out or vomited

What to do as a carer when medication errors happen

1. Stay calm

The first thing to do is to stay calm. Medication errors have the ability to make anyone panic which will affect your ability to think critically and make effective decisions. If you’re too upset, stressed or panicked, explain to a colleague what’s happened and ask them to take over until you’ve calmed down.

2. Be honest

It’s important to remember we are all human and accidents can happen. But by not being honest, this could lead to the person being supported receiving the wrong treatment and getting the wrong advice, which could impact them further.

3. Seek medical advice

The sooner you can seek medical advice, the sooner the person can be checked and/or reassured that they’re okay. If there’s a medical emergency such as a reaction, then you should contact 999 in the first instance.

4. Document everything

Make sure you make a written account of what’s happened so that there’s a clear timeline of events. This should include:

• Who you phoned, including the telephone number you called
• Who you spoke to and the time you spoke to them
• Their advice
• Any services such as A&E, doctors, pharmacies etc that you visited, including the date/time and who you spoke to.

5. Report the incident to your manager

Sit down with your manager and explain what’s happened in as much detail as possible. It’s likely they’ll need to complete an internal investigation into how the incident happened and what steps can be taken to prevent this in the future, so having as much information as possible will help them do this. Some questions you might be asked could include:

• Can you give your account of the medication round? Was it quiet, busy, stressful etc…
• Were you distracted at all?
• Did you feel stressed?
• Did you feel under pressure from other staff or the people being supported?
• Do you feel that you were given enough time to complete the medication task
• What time did you start administering medication?
• Was there anything personal happening that may have affected you?
• Can you confirm if you knew you made a medication error/mistake?
• Can you explain why this error occurred?
• Did you check the MAR chart prior to administering medication?
• Do you understand the MAR chart codes?
• Did you complete the MAR chart after administering the medication?
• Can you think of anything that might help to prevent this error happening again?
• Is there anything else you wish to add?

As part of this process, you’ll likely have your medication administration duties taken away temporarily – this is a necessary safeguarding step that all care services have to take.

Once your service has completed their investigation, they’ll let you know the outcome of this and will discuss any further steps with you directly. Whatever the outcome, be sure to learn from the experience to ensure this doesn’t happen again.

What to do as a manager when medication errors happen

1. Investigate the incident

The error should be investigated internally as soon as possible, to find out exactly what happened and establish the cause.

From experience, I find that getting the person involved to write a reflective account of the incident, incredibly helpful. It helps them to think about the error and reflect on this (top tip – try using some of the questions in ‘5. Speak to your manager’ in the section above as prompts to help frame this). Often staff feel anxious, guilty and upset and direct questioning can make them close up, whilst writing a reflective account in a quiet place can provide much more information.

It’s important that despite the medication error and the outcome of any investigations, that the staff member involved is reassured, supported and communicated with during the process.

During this process, its best practice to temporarily remove the member of staff being investigated from performing medication duties as a safeguarding measure. It’s also good to consult your medication policy and HR team (if applicable) for guidance on how to proceed.

2. Report the error

The person’s next of kin should be contacted to report the medication error. It’s important to remember that if the person has capacity and doesn’t want them to know, that this is respected.

If you’re based in England, you may need to notify the Care Quality Commission about a medication error.  

A safeguarding notification may also need to be submitted. It’s best to contact your local adult safeguarding team for further information.

3. Take steps to prevent future errors

As well as establishing the cause of the medication error, it’s important that we think about how to prevent errors from happening in the future and there are a number of methods to do this, including:

• Re-training staff
• Sharing reflections from previous errors with your team
• Completing regular medication competency assessments for all staff administering meds
• Auditing medication errors for trend analysis
• Regularly reviewing medication training, medication policies and medication procedures, including considering an electronic medication management system
• Creating a culture of whistleblowing and honesty so staff aren’t scared to report errors or concerns.

We all make mistakes

It’s important to remember that we’re all human and will make mistakes. The best thing to do, as a carer or a manager, is to be honest and transparent. By fully understanding medication errors we can reflect on them and prevent them from happening again in the future.

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