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Medicine-related error

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The management of clinical risk has particular relevance for practitioners involved in the preparation and administration of medicines as there is an increasing trend towards litigation in cases of error.

However, the issue of how to deal with medicine-related error within the NHS has often been linked solely to disciplinary processes and the attachment of blame.

Such an approach inevitably leads to an under reporting of error and the potential for harmful practice to go unchecked (Department of Health, 2000).

Given the importance of medicines to the overall healthcare process, the subject of medicines-related error is both poorly researched and poorly understood. Moreover, any analyses of errors have tended to focus on a single profession, which has done little to cast light on the causes of error and more importantly to prevent their recurrence.

A prerequisite for the safe and effective management of medicines in any healthcare organisation is an open and blame-free approach to the reporting of drug-related errors. Such an approach must be founded on the principle of multiprofessional practice and the adoption of standards that reflect the activity being undertaken rather than the practitioner undertaking it.

For example, the standards for the preparation of a parenteral medicine should be the same whether it is prepared at ward level or in the pharmacy aseptic unit. An organisation with a culture that is open to discussing errors will help individual practitioners to feel confident enough to report mistakes and discuss how they can be avoided.

The NMC (2006) supports the use of local multidisciplinary critical incident panels where errors can be explored and improvements to local practice in the administration of medicines can be discussed, identified and disseminated.

The council distinguishes between cases where the error was the result of reckless or incompetent practice or was concealed and those resulting from other causes such as pressure of work and where the incident was reported in the patient’s interest.

National Patient Safety Agency (NPSA)

The NPSA has been active in collating and reporting data on incidents that have occurred in both primary and secondary care settings via its National reporting and Learning System (NRLS). A report published this year on improving the use of medicines in the NHS includes an analysis of medication incidents and outlines the safe medication work programme (NPSA 2007a). It identified that medication incidents were the second most common type of incident reported to the NRLS after patient accidents between January 2005 and June 2006.

The NPSA has also launched its safe medication practice work programme for 2007-2008, which includes five patient safety alerts covering five high risk issues: anticoagulant medicines; liquid medicines; injectable medicines; epidural injections and infusions and paediatric intravenous infusions (NPSA, 2007b).

Managing administration of medicines on wards

The procedure for the administration of medicines often takes place in busy wards and nurses frequently report problems with interruptions and distractions. These problems have been associated with error (Armitage and Knapman, 2003).

Most nurses learn about medicines administration through practical experience rather than formal training and a survey conducted in mental health wards for older people identified problems with nurses crushing tablets, noise and covert administration of medicines (Dickens et al, 2007). The authors concluded that nurses needed annual training about medicines administration as well as clear guidance on covert administration of medicines (Dickens, 2007).

Changing practice to improve the safety of drug administration requires the ward team to examine how and when the drugs are administered and by whom.

The Releasing Time to Care: Productive Ward Programme organised by the NHS Institute for Innovation and Improvement has highlighted how the drug round can be carried out more efficiently and safely on a ward at Luton and Dunstable Hospital. The nurses on the orthopaedic ward described the drug round as chaotic, unstructured, time-consuming and reported concerns that patients were not receiving their medicines at the prescribed time.

As part of the productive ward programme the drug round was recorded on a video and after watching this the team identified changes that have now been implemented:

  • Controlled drugs are administered at the beginning of the drug round;

  • Night nurses collect patients charts so they are ready by the controlled drug cupboard in the morning;

  • Staff ensure drug cupboards contain stock items;

  • Nurses wear red tabards while undertaking drug rounds to signal to others that they should not be disturbed;

  • Patients are not washed in the morning until the drug round is completed (Hunt, 2007).


Department of Health (2000) An Organisation with a memory. London: DH.

NMC (2006) Medicines management. A-Z advice sheet

National Patients Safety Agency

NPSA (2007a) Safety in Doses: Improving the Use of Medicines in the NHS. London: NPSA

NPSA (2007b) Patient Safety Alerts 18-22.

Related articles on

Copping, C. (2005) Preventing and reporting drug administration errors. Nursing Times; 101: 33, 32-34.

Dickens, G. et al (2007) Administering medication to older mental health patients. Nursing Times; 103: 15; 30-31.

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