Drug errors

The Nursing and Midwifery Council (NMC 2002) encourages an open culture in relation to reporting drug errors. When investigating allegations of misconduct related to such errors the Council take great care to identify contextual issues, such as whether the error occurred due to incompetence; whether there was immediate disclosure in the client’s best interests or, conversely, whether it was in some way concealed; or, indeed, whether the error may have resulted from some external cause, such as work pressures.

The NMC therefore urges ward managers to review each case individually and to consider the following:
• the type of drug involved
• the effect on the client
• whether the incident was disclosed and the timeframe involved
• hospital policies
• NMC guidelines
• the environment of care
• any other possible influencing factors
• the nurse(s)’s experience and whether they have been involved in any previous incidents.

In acting in the best interests of clients the procedure given below is recommended in the event of a drug error.

Procedure	Rationale
Inform the following people immediately: medical staff ward manager pharmacist client and their relatives if necessary	To alert medical and pharmaceutical staff to the error and request immediate review of client’s condition. Ward manager informed to assess nursing practice and review possible cause for error. To maintain trust and confidence
Undertake any treatment or intervention prescribed by medical/pharmaceutical staff	To reduce risk of further complications and/ or to counteract the error
Complete an untoward incident form	To identify risk and report to appropriate personnel. To record personal account of incident for further investigations by ward manager
Document the incident in client’s records	Legal requirement to safeguard client and maintain communications through effective documentation
Monitor the client’s condition and report any alteration in condition	To maintain client safety and well-being