Errors, omissions and communication

A medicines error is any mistake in prescribing, ordering, supply, storage, administration, recording or monitoring of medicines. A near miss is an error that is intercepted before it reaches the person. Both indicate weaknesses in the system and should be reported and reviewed.

NICE SC1 and NG67 expect providers to have processes for identifying, reporting, reviewing and learning from medicines-related problems. This includes errors, near misses, adverse effects, refusals, suspected misuse or diversion, capacity concerns and changes in a person's health that affect medicines.

If a resident has a suspected adverse drug reaction or a device problem, follow local arrangements for MHRA Yellow Card reporting, usually with senior or clinical support as set out in policy.

Examples that need escalation

• Wrong person: a medicine is offered or given to the wrong person.
• Wrong medicine or dose: the wrong product, strength, number of tablets or volume is given.
• Omitted dose: a dose is missed, unavailable, delayed or not recorded clearly.
• Duplicate dose: the person may have had the same dose twice.
• Wrong route: a medicine is given by the wrong method or applied to the wrong site.
• Refusal: a person refuses a medicine, especially if repeated or high risk.
• Adverse effects: possible side effects, allergy, falls after medicine changes, excessive drowsiness or sudden deterioration.
• Discharge changes: hospital paperwork, new prescriptions, stopped medicines or dose changes do not match the MAR or available stock.

Communication supports medicines safety. Staff may need to contact seniors, nurses, GPs, out-of-hours services, pharmacists, families, hospital discharge teams, community nurses or safeguarding leads. Report facts: what happened, when, which medicine, dose, route, time, who is affected, the person's current condition, what action has already been taken and what help is needed now.

When medicines information does not match, stop and reconcile. Clear escalation is safer than a confident guess.