Medication Error / Near Miss Incident Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Major Error - Is an incident which results in major harm or death, admissions to hospital for 24 hours or more, or in the service user being rendered unconscious. Major errors must be reported by telephone to the Home Manager and Health and Safety Executive followed by this form. A copy must also be filed at the home and a copy sent to Head Office. The home manager must be notified by telephone at the earliest opportunity, he/she will then contact the area manager and the partners. If the home manager is not available, The Area Manager must be notified by telephone direct. A RIDDOR form must be completed and sent to the Home Manager, Area Manager, Head Office, HSE within 24 hours of the incident, and a copy filed under the type of error at the Home.

• Unresolved Error - (the outcome of the incident is at present unknown) Complete the whole form. A copy must also be filed at the home and a copy sent to the Area Manager, Head Office and where applicable Derbyshire Social Services.

• Minor Error - (The service user has suffered no serious harm) Complete the whole form. A copy must also be filed at the home and a copy sent to the Area Manager, Head Office and where applicable Derbyshire Social Services.

• Near Miss Incident - The service user has suffered no serious harm as the error was avoided. A near miss in medication administration is defined as an incident which might have resulted in an error if it had not been noted and rectified before the error occurred. For near miss incidents, sections 1, 2, 3, 11, 12, 13, 17 and 18 ONLY must be completed. A copy must also be filed at the home and a copy sent to the Area Manager, Head Office and where applicable Derbyshire Social Services.

• Examples of Medication Errors as stated on CN15 P&P:
  Prescribing errors
  Dispensing errors
  Medicines administration errors
  Monitoring errors
  Providing incorrect advice on medicines Administration errors by staff can include:
  Medication given to the wrong Service User
  Incorrect medication given to the Service User, (the administration of medication which has not been prescribed)
  Incorrect dose given, too much or too little medication given
  Medication given via the wrong route
  Medication not given
  Medication given more than once
  Medication given at the wrong time
  Medication not documented
  Medication given after being discontinued
  Wrong dose interval
  Not following ‘warning’ advice when administering, e.g. take with or after food
  Giving a drug to which the Service User has a known allergy
  Giving a drug past its expiry date or which has been stored incorrectly

• 1 - Indicate the level of error:-

  Major Error

  Unresolved Error

  Minor Error

  Near Miss

2 - Details of person completing this form:

• Full Name:

• Job Title:

• Name and address of Care Home:

3 - Details of the medication error or near miss

• Name of Service User:

• Date and time error occurred:

  Date

• Date and time error discovered:

  Date

• Details of the error, please describe what happened including times:

• 4 - Pharmacy Name:

• Pharmacy Telephone Number

• 5 - GP Name

• GP Telephone Number

• 6 - Name(s) and job description(s) of any other staff involved in the incident:

• 7 - Has the service user been informed?

  Yes

  No

• If NO state reason

• 8 - Has the service user's next of kin been informed about the error?

  Yes

  No

• If NO state reason

• 9 - Who was contacted for advice?

  Select GP Pharmacist NHS Direct

  • GP
  • Pharmacist
  • NHS Direct

• Name of person contacted

• Telephone Number:

• Date and Time of contact

  Date

• Details of advice given

10 - Actions taken

• Did you act on this advice?

  Yes

  No

• Was any medical treatment necessary?

  Yes

  No

• Have you informed your line manager?

  Yes

  No

• Has the service user been informed about this advice?

  Yes

  No

• Have you (with the service user's consent if appropriate) contacted a relative or carer about this advice?

  Yes

  No

• Does the service user (or relative) which to take the matter further?

  Yes

  No

• 11- What type of medication error/near miss incident occurred?

  Select Wrong service user Wrong quantity given Wrong strength of medicine administered Wrong form of the medicine Medicine out of date Recording error Medicine not given Medicine given at wrong time Other

  • Wrong service user
  • Wrong quantity given
  • Wrong strength of medicine administered
  • Wrong form of the medicine
  • Medicine out of date
  • Recording error
  • Medicine not given
  • Medicine given at wrong time
  • Other

• Please give details

• 12 - Cause of the error

  Select Unclear labelling instructions caused confusion Wrong service user name Product out of date Interruptions Other

  • Unclear labelling instructions caused confusion
  • Wrong service user name
  • Product out of date
  • Interruptions
  • Other

• Please give details

13 - Action taken to prevent a recurrence (Home Manager to complete)

• Review of systems/procedures?

  Yes

  No

• If yes, state how this has been done

• Employee training?

  Yes

  No

• If yes, state what has been done

• Medication review requested

  Yes

  No

• By When

• Request GP/Pharmacy to improve labeling instructions

  Yes

  No

• Request alternative packaging

  Yes

  No

• Update photo of service user

  Yes

  No

• Other

• 14 - Has a Partner of the Ashmere Derbyshire Group been informed (major error)

  Yes

  No

  N/A

• 15 - Has H.S.E been informed (major error)?

  Yes

  No

  N/A

• 16 - Has the C.Q.C been notified?

  Yes

  No

  N/A

• 17 - Has Derbyshire Social Services been notified (where applicable)?

  Yes

  No

  N/A

• 18 - Signature

  Sign

• Date

  Date