Transcript LSA - Medicines Management & Supervision

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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.
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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.
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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.
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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
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Wrong dose/wrong strength
Omitted medicine
 Incorrect
drug administered
 Medication stored in wrong package
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Regular SOM medications audit of controlled
drugs
Medication errors highlighted at SOM road
shows
Governance management
PHA Midwives and Medicines leaflet
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NMC standards for Medicines Management
2010
Adherence to Trust policies and guidelines
Mentorship support for student midwives
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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).
Activity
Action
Check Medicine
Medicine available
01
(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 patient
Check 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
Documentation
Make accurate record AFTER administration
Date & Time
Nurse’s Initials
Record omission using reason code
Prescription
Patient 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)
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
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‘Lessons Learnt’.
We cannot become complacent
We are accountable practitioners
Be careful!!!