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Procedure

Procedure number: CHS38

Title: Procedure for Managing Drug Errors in the Community Hospitals

Sphere of activity: Standards for Better Health domain:


Community Hospitals Domain 1-Safety-C1a, C4d
Domain 3-Governance-C7a

Distribution: Nursing
staff in East Lancs PCT
community hospitals
Policy statement/key objectives: This document outlines the procedure to follow if a drug
error is made by nursing staff working within the community hospitals.
The procedure has been developed to standardise the process.

Supporting references:
Alderman, C. The Drug Error Nightmare Nursing Standard vol. 12 number 25 1997
Arndt, M. Research in practice: how drug mistakes affect self-esteem. Nursing Times Vol.
90 number 15 1994
Callaghan, S. Doing the round alone. Nursing Times vol. 86 number 44 1990
Cohen et al 12 ways to prevent medication errors. Nursing Feb. 1994
Davis, N. Concentrating on interruptions. Advanced Journal of Nursing March 1994
McGovern, K. 10 Golden Rules for Administering Drugs Safely Nursing March 92
Nixon, P. Homing in on drug rounds. Nursing Times vol. 92 number 16 1996
Rushton, C. et al Confronting unsafe practice: Ethical and Legal issues. Paediatric Nursing
vol. 19 number 3 1993
Watt, S. Measure for Measure. Care Weekly June 1995
White, A. Pharmacology for nursing practice. British Journal of Nursing vol. 3 Number 10
1994
Williams, A. How to avoid mistakes in medicine administration. Nursing Times vol. 92
number 13 1996
Leicestershire & Rutland County Primary Care Trust Policy for managing drug errors.
NMC Standards for medicines management
Author: J Gudgeon Date: February 2009
Title: Matron community hospitals
Directorate/Department: Service Provision
Ratification by: S Hayton
Name: Date:
Title:
Directorate / Department:
Presented to Policies and Procedures Group Date: March 2009

Has this procedure been the subject of an Equality Impact Assessment YES
Review date: February 2011

Version: 1
Compliance with standards for Better Health

Please mark appropriate boxes with an X


Safety C1a C4d

Clinical and cost effectiveness

Governance

Patient focus

Accessible and responsive


care

Care environment and


amenities

Public Health

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PROCEDURE FOR MANAGING DRUG ERRORS IN THE COMMUNITY HOSPITALS

1. INTRODUCTION

This procedure has been drawn up in accordance with the East Lancs Medicines Policy
(revised in 2007)

The aim of this document is to clarify and standardise the procedure to be followed if a
Registered Nurse administers medication incorrectly.

It is good practice for each Service of the Trust to monitor issues relating to the
administration of medicines.

All qualified nurses are governed by the NMC and their guidelines on administration as well
as local policies.

In order to meet the clinical governance agenda, it is important that all incidents involving
medication are reported fully, comprehensively and promptly. They must be fully
investigated and appropriate action taken. This may include retraining of staff and
dissemination of lessons learnt so that all may benefit from the incident.

The term "patient" as referred to throughout this document encompasses patient and client.

The term “doctor” referred to in this document encompasses the role of hospital doctor and
GP.

The term “line manager” as referred to in this document encompasses the role of band 6
sisters and band 7 ward manager.

The aims of this procedure are to ensure:


- the safety and well-being of the patient concerned;
- that all staff are dealt with appropriately and fairly and are offered the level
- of support and mentorship required;
- That incidents are dealt with quickly and any resulting action is taken
promptly e.g. that the responsible line manager and accountable
professional, e.g. the doctor, are informed.

2. DECIDING WHETHER TO PROCEED

This procedure sets out how drug errors within the community hospitals should be
investigated to ensure that the patient's well being is maintained. A drug error can be
defined as;
- giving an individual another person's drug
- giving the wrong drug
- giving the wrong dose
- giving a drug by the wrong route
- exceeding a specified maximum dosage within a specific time period
- giving a drug which is out of date or has been stored incorrectly

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- inappropriate use of PRN medication
- failing to give a required dose of medication without completing the required
- code on the patients drug chart

Missed medication or administering at a different time to that specified on the prescription


does not necessarily constitute an error if there is a valid reason for this.

The line manager needs to give consideration to the drug, the incident and the timing, and
from this a decision is made whether to go ahead with the procedure.

3. THE PROCEDURE

3.1 Clinical Responsibilities / Action

This section of the procedure is to ensure that the safety and well being of individual
patients are maintained. When a drug error has occurred staff should ensure the following
procedure is carried out:

1. An assessment of the patient’s condition is undertaken.

2. Medical staff are advised of the error and asked for advice. In the event of a
doctor's error the consultant will be informed. In the event of a GP’s error the
Clinical Governance Lead for the PCT will be informed (Dr John Haworth 01282
878644).

3. The line manager or senior nurse on duty is advised of the error and asked for
advice; the manager or senior nurse should ensure that the individual does not
administer drugs until a full investigation has been carried out.

4. Following consultation with medical staff the patient and / or their main carer are
advised that an error has occurred by the nurse in charge of the area. The
patient and their carer are supported through the process. All information is
clearly documented.

5. The well being of the patient is monitored throughout. All advice is clearly
documented. Any action advised is carried through.

6. An incident form will be completed, including the risk outcome matrix (as this will
identify who will need to do the full investigation and who will need to be
contacted i.e. on-call manager/ director) and sent to the line manager within 24
hours. The appropriate professional advisor will be notified in accordance with
the Medicines Incidents Reporting procedure (see Trust Incident policy)

7. All relevant staff on duty at the time of the error will make statements at this
time.

8. A detailed entry is made into the individual patient’s notes.

9. Information is handed over in detail at shift change.

10. The well being of staff is monitored throughout and support offered if necessary.

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3.2 Management Responsibilities / Actions

When a drug error occurs it is the responsibility of the line manager or senior nurse on duty
to;
1. Ensure that a decision regarding the competence of the individual concerned to
continue to practice is taken. However, in all cases the individual will be prevented
from administering drugs pending the outcome of the drug re-assessment and
investigation. They should ensure that the recipient is suffering no ill effects and
that medical advice has been sought.

2. The line manager has responsibility for guiding / supporting the registered nurse
through this process and ensuring lessons learned are shared. Additional clinical
supervision should be made available to the individual to ensure that they have an
opportunity to undertake a detailed reflection on the events surrounding the error.

3. The line manager is responsible for carrying out a preliminary investigation, and
ensuring the procedure has been followed appropriately. Initial documentation will
be forwarded promptly to the Trust headquarters within 24 hours / or next working
day of the error being identified.

4. The full investigation, including recommendations and collecting statements and


evidence as appropriate, should be completed within 7 days.

5. The investigating manager should ensure that forms are completed and statements
are taken within 24 hours of the incident.

6. The investigating manager should undertake a review of the incident and


associated systems and processes. This should include making recommendations
to minimise risk of recurrence.

7. On completion of the investigation the line manager will discuss the incident and
findings with the Senior Nurse and, where relevant, with the ISDM and Head of
Nursing. Recommendations and outcomes will then be agreed.

8. A letter confirming the investigation findings, actions agreed and consequences of


any further drug errors to be sent to the individual(s) involved in the error.

9. All documentation to be kept on the individual’s personal file.

10. The incident reporting team will maintain records of all drug errors within the PCT.

4. OUTCOMES

4.1 Following investigation the manager will contact the human recourses manager to
discuss before making a decision whether or not to pursue disciplinary action.

4.2 In all cases, on completion of an investigation an assessment of competency to


administer drugs MUST be carried out. In the majority of cases this will be carried
out by the line manager responsible for that person.

4.3 On completion of the investigation it is recommended that the assessment takes


place within 7 days. (See appendix 1).

4.4 If the drug error has occurred within 12 months of a previous drug error, the
"Managing Performance” policy must be instigated and guidance sought from HR.

4.5 The recommendations should be implemented, learning outcomes and lessons


learnt disseminated anonymously via the clinical governance systems.

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5. ASSESSMENT

5.1 For the qualified nurse the form at appendix 1 should be used.

5.2 The nurse should attain full competence, which is based on the NMC standards for
The Administration of Medicines and the National Workforce Competences
CHS71, CHS3

5.3 Individuals who are not fully competent will need to be supported through the
Fitness to Practice Policy within an agreed time frame.

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APPENDIX 1
DRUG ASSESSMENT FOR QUALIFIED NURSES FOLLOWING A DRUG ERROR
Name: ………………………………… Name of assessor:………………………

Area/Base: …………………………… Date: ………………………


SECTION A

Through discussion and demonstration the qualified nurse must attain competency in all
areas.

(Please tick as appropriate)


Signature and name of assessor…………………………………………

Competency agreed YES/NO signature of nurse…………………………………

Comments

APPENDIX 1

SECTION B

Through discussion and demonstration the qualified nurse will demonstrate a level of
knowledge and understanding in the good practice surrounding drug administration.

Local good practice guidelines.

Records

Theoretical knowledge of drugs used within area

Role of others in safe administration

Care planning and drug administration

SECTION C

1. The qualified nurse will carry out a teaching/information giving session to a


group of staff on one aspect of drug administration which could be;

 Safe drug administration

 A specific drug

 When medication changes

 Standards on drug administration

 Records and drug administration

 Care plans and drug administration

 Any other area relating to drug administration and their area of work

 Any area related to the drug error concerned

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CHS3: Administer medication to individuals
Status: National Occupational Standards (NOS)

About this workforce competence


This workforce competence covers the administration of medication to individuals and monitoring the effects.
This role is complex and will not be the role of all care staff, only those designated to undertake this activity
according to their expertise and employers decisions.

The workforce competence applies to all medication used for and by individuals, both prescribed and non-
prescribed. This includes immunisation and vaccination. This workforce competence is intended to be used in
a variety of care settings including hospitals, nursing and residential homes, hospices, and community settings
including the individual's own home and GP surgeries.

This workforce competence does not cover the use and administration of intra-venous medication.

Users of this competence will need to ensure that practice reflects up to date information and policies.

This competence replaced HCS I18 and Diab_HD1 during rationalisation of the database.
Links
This workforce competence has indicative links with the following dimension and level within the NHS
Knowledge and Skills Framework (October 2004):
HWB5: Provision of care to meet health and wellbeing needs
Level 3: Plan, deliver and evaluate care to meet people's health and wellbeing needs
Keywords
Origin
This is a new workforce competence developed for Clinical Healthcare Support by Skills for Health.
Glossary
This section provides explanations and definitions of the terms used in this workforce competence. In
competences, it is quite common to find words or phrases used which you will be familiar with, but which, in the
detail of the competence, may be used in a very particular way.

Additional protective equipment includes: types of personal protective equipment such as visors,
protective eyewear and radiation protective equipment

Contaminated Includes items contaminated with body fluids, chemicals or


radionuclides.
Any pack/item opened and not used should be treated as
contaminated

Individuals the person who is to receive the medication, this might be an adult
or child

Medication administration record denotes the term used for the documentation on which the
medication has been ordered/prescribed - this will vary across
care settings and environments, such as hospital and community
settings, including medications prescribed by GPs and dispensed
by community pharmacists where the instructions will be found on
the medication packaging

Medication information leaflet Contained inside bought and some prescribed medications.

Personal protective clothing Includes items such as plastic aprons, gloves - both clean and
sterile, footwear, dresses, trousers and shirts and all-in-one
trouser suits.
These may be single use disposable clothing or reusable clothing
Scope
This section provides guidance on possible areas to be covered in this competence.

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Adverse reactions include:
a) swelling
b) allergic skin reaction
c) tachycardia / bradycardia
d) anaphylaxis
e) hypertension / hypotension
f) pain on injection

Appropriate action includes:


a) call for help
b) deal with collapse

Equipment includes:
a) medicine trolley
b) medicine pot
c) spoons
d) syringes
e) containers
f) wipes
g) drinking glasses
h) water jug
i) disposal bag
j) medication administration record sheets/charts

Immediate problems include:


a) refusal to take administration
b) inability to take the medication e.g. nil by mouth, asleep,
collapse, anaphylaxis

Methods (check identity) include:


a) verbally with the individual
b) using other communication methods
c) identification bracelet

Physiological measurements include:


a) blood pressure - possibly lying and standing
b) pulse rate
c) temperature
d) respiratory rate - some of these will be taken before
administration, others will be taken after, and some will be
monitored before and after

Relevant staff includes:


a) person in charge ( e.g. nurse, midwife, social worker)
b) pharmacist
c) medical staff

Routes include:
a) oral
b) topical - including skin creams
c) eye/ear or nasal drops
d) inhaled
e) for injection - intra-muscular/sub-cutaneous

Standard precautions a series of interventions which will minimise or prevent infection

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and health and safety measures and cross infection, including
a) hand washing/cleansing before during and after the activity
b) Use of personal protective clothing and additional protective
equipment when appropriate.
it also includes handling contaminated items, disposing of waste,
safe moving and handling techniques and untoward incident
procedures

Storage Conditions include:


a) security,
b) temperature,
c) light;
d) and issuing and accounting for drugs
Performance Criteria
You need to:
1. Apply standard precautions for infection control any other relevant health and safety measures
2. Check that all medication administration records or protocols are available, up to date and legible
3. Report any discrepancies or omissions you might find to the person in control of the administration and to
relevant staff as appropriate
4. Read the medication administration record or medication information leaflet accurately, referring any
illegible directions to the appropriate member of staff before administering any medication
5. Check and confirm the identity of the individual who is to receive the medication with the individual
themselves, and your assistant (if applicable), using a variety of methods, before administering medication
6. Check that the individual has not taken any medication recently and be aware of the appropriate timing of
medication
7. Obtain the individuals consent and offer information, support and reassurance throughout, in a manner which
encourages their co-operation and which is appropriate to their needs and concerns
8. Select, check and prepare correctly the medication according to the medication administration record or
medication information leaflet
9. Select the route for the administration of medication, according to the patient's plan of care and the drug to
be administered, and prepare the site if necessary
10. Safely administer the medication:
Following the written instructions and in line with legislation and local policies
In a way which minimises pain, discomfort and trauma to the individual
Report any immediate problems with the administration
11. Check and confirm that the individual actually takes the medication and does not pass medication to others
12. Monitor the individual's condition throughout, recognise any adverse effects and take the appropriate
action without delay
13. Clearly and accurately enter relevant information in the correct records
14. Maintain the security of medication throughout the process and return it to the correct place for storage
15. Monitor and rotate stocks of medication, maintain appropriate storage conditions and report any
discrepancies in stocks immediately to the relevant staff
16. Dispose of out of date and part-used medications in accordance with legal and organisational requirements
17. Return medication administration records to the agreed place for storage and maintain the confidentiality of
information relating to the individual at all times
Knowledge and understanding
You need to apply:
Legislation, policy and good practice
K1. A factual awareness of the current European and national legislation, national guidelines and local policies
and protocols which affect your work practice in relation to the administration of medication, including:

 drug storage (such as medical and legal regulations, local pharmacy policy)
 drug handling, preparation and administration
 health and safety when dealing with drugs (e.g. COSHH)

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K2. A working understanding of your responsibilities and accountability in relation to the current European and
national legislation, national guidelines and local policies and protocols
K3. A factual awareness of the importance of working within your own sphere of competence and seeking
advice when faced with situations outside your sphere of competence
K4. A working understanding of the importance of applying standard precautions to the administration of
medication and the potential consequences of poor practice, including safe methods of handling and disposing
of hazardous equipment and materials, such as sharps and medication
K5. A working understanding of the hazards and complications which may arise during the administration of
medications and how you can minimise such risks
Care and support of the individual
K6. A working understanding of the importance of offering effective verbal and non-verbal support and
reassurance to individuals, and appropriate ways of doing so, according to their needs
K7. A working understanding of the importance of communicating effectively and how communication
differences may be overcome
K8. A working understanding of the factors which may compromise the comfort and dignity of individuals during
drug administration - and how the effects can be minimised
Pharmacology
K9. A working understanding of the common types of medication and rules for their storage
K10. A working understanding of the effects of common medication relevant to the individual’s condition
K11. A working understanding of medications which demand for the measurement of specific physiological
measurements and why these are vital to monitor the effects of the medication
K12. A working understanding of the common adverse reactions to medication, how each can be recognised
and the appropriate action(s) required
K13. A working understanding of the common side effects of the medication being used
K14. A working understanding of the different routes of medicine administration
K15. A working understanding of the information which needs to be on the label of medication, both prescribed
and non-prescribed, and the significance of the information
Materials and equipment
K16. A working understanding of the various aids to help individuals take their medication
K17. A working understanding of the types, purpose and function of materials and equipment needed for the
administration of medication via the different routes
K18. A working understanding of the factors which affect the choice of materials and equipment for the
administration of medication to individuals
Procedures and techniques
K19. A working understanding of how to read prescriptions/medication administration charts to identify:

 the medication required


 the dose required
 the route for administration
 the time and frequency for administration

K20. A working understanding of how to prepare the medication for administration using a non-touch technique
K21. A working understanding of how you would check that the individual had taken their medication
K22. A working understanding of how you dispose of different medications
Records and documentation
K23. A working understanding of the importance of correctly recording your activities as required
K24 A working understanding of the importance of keeping accurate and up to date records
K25 A working understanding of the importance of immediately reporting any issues, which are outside your
own sphere of competence without delay to the relevant member of staff
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11
CHS71: Help individuals to use nebulised medication safely and
effectively
Status: National Workforce Competence (NWC)

About this workforce competence


This workforce competence covers using nebulised medication and should be read in conjunction with CHS3
Administer medication to individuals, MCN21 Administer medications to babies. It also includes adhering to
Health and Safety and the Control of Substances Hazardous to Health legislation.

This competence is intended for use in a variety of care settings including hospitals, nursing and residential
homes, hospices, and community settings including the individual's own home and primary health care centres

Users of this competence will need to ensure that practice reflects up to date information and policies.

Links
This workforce competence has indicative links with the following dimension and level within the NHS
Knowledge and Skills Framework (October 2004):
HWB4: Enablement to address health and wellbeing needs
Level 3: Enable people to address specific needs in relation to health and wellbeing
Keywords
nebuliser, administration of medications, drug administration, nebulised drugs, air compressor
Origin
This workforce competence has been developed by Skills for Health.
Glossary
This section provides explanations and definitions of the terms used in this workforce competence. In
competences, it is quite common to find words or phrases used which you will be familiar with, but which, in the
detail of the competence, may be used in a very particular way.

Air compressor A compressor that takes in air at atmospheric pressure


and delivers it at a higher pressure

British National Formulary (BNF) A publication available in all pharmacies and on-line. It
provides up to date guidance on the selection,
prescribing, dispensing and administration of
medicines

Control of Substances Hazardous to Health Statutory regulations with a requirement to promote


(COSHH) safe storage and handling of potentially hazardous
substances and equipment

Facemask/mouthpiece Alternative methods of delivering the nebulised


solution

Filter The renewable part of the air compressor which is


changed annually or more frequently to ensure that the
air compressor works to its optimum effect

Nebulisation The process used to turn liquid into a fine mist which
may be used for delivering medication to the
respiratory tract

Valid consent If you consent to something, you agree to do it or allow


it to be done. ‘Valid consent' means that you have
been given the relevant information and have the
necessary knowledge to decide whether the course of
action is the right one for you.
Scope

12
This section provides guidance on possible areas to be covered in this competence.

Adverse reactions may include:


a) discomfort or distress
Refer to the BNF for details of adverse reactions

Dealing with adverse reaction correctly may include:


a) stopping medication
b) refer to the BNF

Health and safety measures includes:


a) how to clean and maintain the equipment safely
b) how to dispose of waste and hazardous materials
correctly
c) emergency equipment (in acute settings)
d) universal precautions
e) risk assessment
f) safe moving and handling techniques

Individuals may include:


a) adults
b) children and young people
c) babies and infants

Prescriber may include:


a) doctor
b) nurse
c) physiotherapist
d) pharmacist
e) paramedic
Performance Criteria
You need to:
1. Discuss treatment options with individuals and
a) Explain and demonstrate the procedure for using a nebulised medication
b) Inform them of the adverse reactions
c) Discuss maintenance servicing of equipment and the appropriate use of face masks or mouthpieces
2. Ensure the face mask or mouthpiece is selected according to recommended procedures and the request of
the prescribing clinician
3. Ascertain that the individual is aware of the health and safety measures relevant to using nebulised
medication
4. Ensure that individuals can assess whether the equipment is working correctly and who to contact if and
when a problem occurs
5. Ensure the individual is aware of the importance of when to use a new nebulised chamber and when the
filter should be changed
6. Ensure that the individual knows how to administer nebulised medication as prescribed by a prescriber
through the equipment according to national guidelines and local protocols
7. Help the individual find a comfortable position within the constraints of the treatment/environment
8. Teach the individual to recognise discomfort or any adverse reactions during the treatment and instruct both
the individual and carer to take appropriate action
9. Ensure that the individual has details of who to contact should they be concerned about their condition
10. Ensure the individual is aware of the importance of washing and drying the nebulised chamber after each
use to prevent infection
11. Ensure the individual understands the importance of maintaining the air compressor
12. Record the advice given to the individual in the patient held records, as appropriate, according to national
guidelines and local protocols
Knowledge and understanding

13
You need to apply:
Legislation, policy and good practice
K1. A working knowledge of your responsibilities and accountability under the current national legislation (in
particular health & safety and COSHH) guidelines and local protocols with respect to the use of nebulised
medication
K2. A factual knowledge of the importance of working within your own sphere of competence and seeking
advice when faced with situations outside your sphere of competence
K3. A working knowledge of the hazards and complications which may arise during the use of nebulised
medication and how such risks can be minimised
K4. A working knowledge of the range of information which should be made available to the individual
K5. A working knowledge of the local guidelines for risk management and adverse incidents
Materials and equipment
K6. A working knowledge of the equipment to be used with nebulised medication
Procedures and techniques
K7. A working knowledge of the principles of nebulisation
K8. An in-depth understanding of the suitability of nebulised medication for specific groups of individuals
K9. An in-depth understanding of the risks and complications of using nebulised medication
K10. An in-depth understanding of the methods to assess and monitor the individual during the use of
nebulised medication
K11. A working knowledge of the factors which may compromise the comfort and dignity of individuals during
the use of nebulised medication - and how the effects can be minimised
K12. An in-depth understanding of nebulised medications
K13. An in-depth understanding of accepted best practice when using nebulised medications
K14. A factual knowledge of the contraindications to using nebulised medication
Valid Consent
K15. A factual knowledge of legislation and legal processes relating to valid consent
K16. A working knowledge of methods of obtaining valid consent and how to confirm that sufficient information
has been provided on which to base this judgment
K17. A working knowledge of the actions to take if valid consent cannot be obtained
Communication and interpersonal relationships
K18. A working knowledge of how to adapt communication styles in ways which are appropriate to different
people
K19. A working knowledge of how to confirm that individuals and/or carers have understood the instructions
and guidance provided
K20. A factual knowledge of the importance of providing individuals with opportunities to ask questions and
increase their understanding
K21. A working knowledge of the key theories of learning and development and their application in a healthcare
context
K22. A working knowledge of individual learning styles and the factors influencing effective learning
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14
MANAGEMENT OF A DRUG ERROR

 Inform
clinical
governance
lead if GP
error
Staff who fail the assessment will be supported using the Managing Performance and
Fitness to Practice policies

Drug error policy followed:


 An assessment of patients condition is undertaken
 Medical staff are informed of the error and asked for advice
 Nurse
Monitoring in charge to inform patient/carer that there has been a drug error and they are supported
information
through the process, all information is clearly documented
 The well being of the patient is monitored throughout
To monitor that this policy is implemented fairly it would be useful if the staff member would
 All advice is documented and advised actions are carried out
complete the following questions this is optional
 An incident form including risk assessment matrix is completed (as this will identify who will
need to do the full investigation and who will need to be contacted i.e. on-call manager/ director)
What ageandbracket areline
sent to the youmanager
in? 18-30 31-40
within 24 hours. 41-50 professional
The appropriate 51-65 advisor will be
notified in accordance with the Medicines Incidents Reporting procedure (see Trust Incident
What doPolicy).
you describe as your ethnicity?
 All relevant staff will make statements
 Male/female?
Are you A detailed entry is made in the patients notes
 Information is handed over in detail at shift change
Whatreligion arebeing
The well you?of the staff is monitored and support offered
 Staff involved to refrain from administering drugs until they have successfully completed a
competency
What is your sexual assessment.
orientation?

Policy implemented immediately following error YES NO

If no why not?

Investigation completed within 3 working days YES NO

Competencies completed within 7 days YES NO

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