 Definition of medicines management  Incidents reported  How medications errors are reported  Actions taken to prevent reoccurrence  Role of the Supervisor in relation to medications errors.

 The administration of a medicine is a common but important clinical procedure. It is the manner in which a medicine is administered that determines the outcomes for the patient. Eg: clinical benefit or adverse effect.  The administration of medicines has been demonstrated to encompass many areas for potential error.

 In 2013 there were 6 reported medicines incidences.  Most of these were ward related.  Most of these were simple mistakes from not checking prescribed dosage and names of medications properly.  These were reported through IR1’s and investigated accordingly.

 Governance.  Risk Management Midwife.  Ownership.  Ward Manager/Team Leader reporting same.  Other staff or women themselves.  Complaints management.

Risky business – highlights most frequent incidents of medications errors  Wrong dose/wrong strength  Omitted medicine  Incorrect drug administered  Medication stored in wrong package

 Regular SOM medications audit of controlled drugs  Medication errors highlighted at SOM road shows  Governance management  PHA Midwives and Medicines leaflet

 NMC standards for Medicines Management 2010  Adherence to Trust policies and guidelines  Mentorship support for student midwives

 Action plan. ◦ Reflective practice ◦ Observed medication administration assessment tool ◦ Medicines Management update through C.E.C. ◦ Self assessment of medication knowledge tool ◦ Good record keeping.(NMC 2012).

ActivityAction Check MedicineMedicine available (if not arrange supply) Name of Medicine Strength Form Expiry Date Opens one pack at a time Removes dose (‘non-touch’) Returns container to trolley or replaces / orders if last dose Administration to patientCheck patient hasn’t had dose Check patient’s condition – should medicine be withheld? Check patient’s identification Check patient’s allergies Take medicines to patient and remain until doses taken Interaction with patient person centred DocumentationMake accurate record AFTER administration Date & Time Nurse’s Initials Record omission using reason code PrescriptionPatient Name Unit Number Name of Medicine Dose (within normal limits) Route Timing and Frequency (fits with expected time of administration) Start date Signature Allergies (used to check medicine)

 ‘Lessons Learnt’.  We cannot become complacent  We are accountable practitioners  Be careful!!!