A Medication error can occur in the process of prescribing, dispensing, preparing, administrating, monitoring, or providing medicine advice, regardless of whether any harm has occurred. Examples of medication errors can include the following:

  • Omissions - any prescribed dose not given.
  • Wrong dose administered, too much or too little.
  • Extra dose given.
  • Wrong medication - the administration to a service user of any medicine not authorised for them.
  • Wrong dose interval.
  • Wrong administration route - administration of a medicine by a different route or in a different form from that prescribed.
  • Administration of a drug to which the service user has a known allergy.
  • Administration of a drug past its expiry date.

If staff are aware or become aware of an error and the service user is unwell, medical assistance must be sought immediately. In all situations, staff must contact the manager immediately, ensure they make a record on the service users Medication Administration Record (MAR) and in their daily records.

If other providers are supporting the service user, staff will need to follow the Kirklees' shared protocol for home care packages.

The manager will need to ensure the following:

  • Seek advice from the GP or appropriate health professional immediately and follow their advice accordingly.
  • Record any communications and actions taken.
  • Follow the providers' own medication policies and procedures and reporting systems that must be in place for staff at all levels to follow and needs to include 'medication errors', incidents and near misses.
  • Notify other relevant staff and providers, local safeguarding and any other relevant service user family members and/or representatives of the error, actions taken and any changes or deterioration in the service user's health or behaviour.
  • Review the service user's medication support as may be required.
  • Encourage a culture where staff are encouraged to report errors, incidents and near misses and information to encourage shared learning and reduce repeated incidents.
  • Ensure investigations are carried out and recorded including any actions taken such as training to staff and reviewing of procedures.

Please note that although there is no requirement to notify CQC about medicines errors, you must tell them if a medicines error has caused:

  • A death.
  • An injury.
  • Abuse, or an allegation of abuse.
  • An incident reported to or investigated by the police.
  • Where relevant, you should make it clear that a medicine error was a known or possible cause or effect of these incidents or events being notified.

Further guidance

Managing medicines for adults receiving social care in the community | Guidance | NICE

Reporting medicine related incidents | Care Quality Commission (cqc.org.uk)

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