04 Oct Managing (and learning from) medication errors.
In this update, I will cover which types of medication error need reporting to the CQC and safeguarding, as well as how to investigate and learn from medication errors.
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I’m often asked by care providers to work with them to reduce medication errors. It’s a complex area, and I’ll provide some of the advice I give in this article.
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What do most companies get wrong, and what should they be doing instead?
Do any of these measures sound familiar?
Punishing staff (intentionally or unintentionally) when they make errors
The directors might tell me they have a fair blame culture, but when I talk to the staff they tell me a few horror stories. Even if staff believe they’ll be blamed, they either won’t report errors, or they’ll give less input into investigations. And yes, there are still companies out there with “three strikes and you’re out” type policies. You’ll just drive the problem underground.
I ask companies to have a clear statement in their medication policy which talks about “fair blame” or “a just culture”. Something that staff can gently show a manager who might still be talking a blame approach.
I’m not saying it’s open season on errors. There are times when we might need to suspend or dismiss someone (hence saying “just culture” now rather than “no blame”). There is a line, but where is it?
That’s where a tool from Professor James Reason comes in: The “Incident Decision Tree”. It’s a flowchart that asks four key questions about the incident. It helps you objectively differentiate system from human errors. With human errors, it then helps you chose the most appropriate response:
- training and supervision
- referral to occupational health
- suspension
- disciplinary action
Reporting errors
Do you inform the CQC? Ask 5 different CQC staff, and get 5 different answers. What’s the official line? In “Statutory notifications: Guidance for non-NHS trust providers”, the CQC states:
“There is no requirement to notify CQC about medicines errors, but a notification would be required if the cause or effect of a medicine error met the criteria to notify one of the following:
- a death
- an injury
- abuse, or an allegation of abuse
- an incident reported to or investigated by the police”
CQC get this information from the Health and Social Care Act Regulations 2014 which defines notifiable harm: essentially prolonged (over 28 days) harm, pain or shortened life expectancy. Check regulation 20, paragraph 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) for full details (I’ll not reproduce them here as I’m trying to keep this article short!).
In terms of “an incident reported to or investigated by the police”, this could be staff stealing medicines and definitely should be where controlled drugs go missing and are still unaccounted for after taking into account recording errors.
Which errors need reporting to safeguarding?
Ask 10 different safeguarding teams and you’ll get 10 different answers! Which is why NICE step in here and make this suggestion to Safeguarding boards (on page 79 of their Managing Medicines in Care Homes Guidelines):
“A safeguarding issue in relation to managing medicines could include the deliberate withholding of a medicine(s) without a valid reason, the incorrect use of a medicine(s) for reasons other than the benefit of a resident, deliberate attempt to harm through use of a medicine(s), or accidental harm caused by incorrect administration or a medication error.”
Ideally, Safeguarding should take the same line as CQC: death, harm, deliberate intent, or where police are involved. However, check which errors your local Safeguarding boards want to be notified about, and perhaps make them aware of the advice issued by NICE.
In terms of internal reporting, have one person in your organisation responsible for collating all incidents, ensuring that root cause is done, systems changed, lessons learnt and spread. Report everything internally, but follow the advice above regarding CQC and safeguarding.
Root cause investigation of errors
And here is where it often goes wrong…
I often ask organisations to show me their errors. Here’s what I get, either:
- Nothing – even if we are just providing them with medication training (rather than consultancy on medication errors) I ask to see errors. This ensures the medication training can be focused. I normally get nothing back (despite repeated requests). It tends to be the larger organisations. Your guess is as good as mine…
- A spreadsheet with top level information. I’ve seen organisations who spend ages meticulously recording, categorising and measuring errors rates. They then discuss the spreadsheet at senior management meetings and scratch their heads. But no action is taken beyond this. Instead of spending time measuring the errors, sort out your reporting system and make sure root cause investigations are happening. Ditch the spreadsheet and look at the actual error forms.
- The actual error forms. Success! Ah… hang on… there’s no detail in them… either one-liners from busy managers, or essays that don’t get to any root causes.
I start with the incident form template they are using. I always recommend a form specific for medicines-related incidents (download ours here: Downloads/Resources). Many forms are too lengthy, generic for all types of incidents, and don’t guide people through the root cause process.
Make sure that you have local (redacted) copies of the incidents available for staff to study and learn from (including new starters). With the error forms that have lengthy responses, often they fail to identify the root cause(s) and are often essays designed to cover “one’s rear end”.
Root cause investigation takes a little training, but mainly time, and who has time in social care these days? It is worth it though. I’ll go through root cause investigating on the online workshop.
Learn from your errors and spread the learning
In my experience, most errors are systems problems. Once you have established root cause(s) address the relevant systems.
Have you got 10 different medication policies for each of your 10 services? or a 70-page policy containing a lot of well-meaning general statements that no one really reads?
You need a set of concise, simple standard operating procedures that can be changed as soon as you want to fix systems problems (rather than that 70 page policy which needs to wait 3 months to be changed and ratified by the medicines committee).
You then need to share this with your trainer (me!) and all the staff. Why not have a live messaging system that tells all staff about the error and the measures you are now putting in place?
If you want more information or want to discuss how this might affect you, call us (01273 917210), email us or click here to find out about our open workshops running this month.
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