For those of you working in acute settings you will want to review the Healthcare Safety Investigation Branch’s report on Inadvertent administration of an oral liquid medicine into a vein.
The events in question related to a nine-year-old child who inadvertently had oral, liquid midazolam injected into a vein (when the midazolam had been prescribed to be given intravenously).
The investigation reviewed the effectiveness of current processes for the storage of medicines, equipment design and the prescribing, preparation, checking and administration of medication. The terms of reference are set out at page 19.
There were eight reference event findings and 24 national investigation findings (see pages 7 and 8). HSIB observe that the structure and culture of the NHS make it difficult to share best practice.
While this investigation related to the use of midazolam as a sedative in advance of a renal kidney biopsy, many of these findings will resonate in other areas, such as no local standard operating procedure and local policies not followed or understood. People apparently told the investigation team that they “rarely read the policies due to their length, number and complexity.”
HSIB have made four safety recommendations and seven safety observations.
Recommendations
- NHS Improvement set standards for all issuers of patient safety alerts which make clear that issuers should assess for unintended consequences, the effectiveness of barriers and provide advice for implementation and ongoing monitoring.
- NHS Improvement support the development of necessary knowledge, skills and capacity for the effective operationalisation of hazard identification and risk analysis at a national, regional and local level.
- Royal College of Physicians to provide leadership in recommending post graduate learning needs and activities to standardise professional development in medicines safety processes.
- NHS Improvement undertake a formal evaluation of banding, time and resource given to the Medication Safety Officer role.
A summary is set out at pages 61 – 64.
The report notes that recent research estimated that 237 million medication errors occur at some point in the medication process in England per year. 72 per cent were noted to have little or no potential for harm. However researchers estimated that 66 million potentially significant errors occur per year.
The report also refers to the National Reporting and Learning System data which showed over 1 million medication incidents from April 2013 to March 2018 – of which 88 per cent were 'no harm' incidents. The number reported has increased year on year.
Jill Mason, Partner and Head of Health and Care
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