SIGNIFICANT EVENTS REVIEW
2012 - 2013
Meeting Date: 09.09.2013
Present Dr E J Doris (Senior Partner and Complaints Clinical Lead) and Sarah Brundish (Practice
Manager and non-clinical Complaints Lead)
In line with the requirements of The Care Quality Commission’s Outcome 16 (Regulation 10) Assessing
and Monitoring the Quality of Service Provision, an annual review has taken place to discuss the
Significant Events which have occurred within the practice during the period April 2012 – March 2013, in
order to improve the service by learning from adverse events.
Overall a total of 10 incidents were thought to be serious enough to warrant a Significant Event
investigation and report. These varied in diversity but have been summarised below:
A.
B.
C.
D.
E.
Prescribing
Communication problem
Palliative Care
Information Governance
Health & Safety
3
2
2
2
1
Summary of Events and Changes to Practice Procedures
1.
Non clinical member of staff added acute medication to a patient’s records, which was medication
which should only have been prescribed by the hospital. Confusion subsequently arose as to
where the patient should access the medication from and also the form of the medication, ie brand
or generic version.
Repeat prescribing protocol amended to ensure non-clinicians are not permitted to add any
medication to a patients records. Similar requests for medication which are not on a
patient’s records must be sent through to their usual GP for authorisation, which the
clinician is then responsible for adding to the prescription template
2.
A prescription was sent via Royal Mail to a local pharmacy for dispensing. There were a number of
medications within the prescription which are classed as “Controlled Drugs”, ie highly addictive and
potentially dangerous. The pharmacy contacted the practice to report non-receipt of the
prescription. The practice tried to locate the prescription through Royal Mail unsuccessfully. Any
prescribing issues / problems involving Controlled Drugs must be reported mandatorily to the local
Accountable Controlled Drugs Officer within the PCT/CCG. A report was made as required.
The outcome of this review concluded that our Controlled Drug protocol should be
amended to reflect a change in our processes involving the posting of prescriptions for
CD’s. The decision was made to no longer permit the posting of CD’s through Royal Mail.
Either the patient must collect the prescription themselves, or if this is not possible, the
patient must arrange for the prescription to be collected by a pharmacy who offers this
collection service.
3.
A letter received from the hospital regarding a patient’s medication had not been actioned, and
was found 2 years later when a further change to medication had been requested. The patient had
remained stable throughout this period of time, and had been seen by the hospital on 5 occasions
during the period. Investigations showed the patient continued to ask for his original item of
medication, despite also being informed by the hospital of the need to change.
The outcome of the review concluded that patients ought to be asked to see their GP if
medication changes are advised, to ensure the GP and the patient are both very clear on
instructions sent from secondary care. A letter was sent to the appropriate hospital
department highlighting the significant event, and asking whether patient’s medications are
routinely reviewed at hospital appointments. In addition to this the practice has
implemented a new process with regard to hospital discharge letters, in that all are now
processed by a member of the nursing team before being filed to the patients records, to
ensure clinical actions are noted and taken.
4.
Both of these events raised the question as to whether the practice could have provided a more
structured approach to the palliative care received by the patients concerned.
As a result of these reviews, the practice agreed that communication between the agencies
involved in the delivery of palliative care could be improved upon, and has agreed and
implemented a new protocol to ensure these recommendations are actioned.
5.
Patient was advised to change dosage of current medication. Receptionist rang to speak with
patient, but was unable to make direct contact. Message left on an answerphone. Patient
commended medication, but unfortunately took the wrong dose. This was not noted until patient
attended opportunistically at a later date. Patient misunderstood message left on answerphone.
The review concluded that there was no way of being certain what message had been left
on the patient’s answer machine. Therefore the misunderstanding could have been on
either side, however it resulted in the patient taking the incorrect dose of medication.
Although the patient didn’t come to any harm, the practice decided this was an
unacceptable risk, and has since changed its protocol with regard to messages for patients
regarding medication. These are now only sent via a GP, either by phone, text or letter, to
ensure clinical risks such as this are minimised in the future
6.
Patient died and circumstances were discussed with the Coroner. Approximately 2 weeks, the
same doctor was asked to sign a prescription for a patient with exactly the same, uncommon
name, with very similar medical histories. The Doctor queried why this prescription had been
requested. Investigations confirmed they were in fact two separate patients.
The subsequent review of this event reiterated the fact that Information Governance
procedures had not been fully implemented, and how important it was that these were
followed fully at all times. Staff were informed to check name, dob and addresses for all
patients whose notes are opened for any reason
7.
Needlestick injury sustained by a member of the cleaning staff.
Needlestick injury protocol updated and laminated for all consulting rooms.
8.
Patient received a duplicate vaccination in error. No clinical harm came as a result, but it became
apparent that recording problems existed.
The review concluded that a more structured approach to organising vaccinations
programmes for patients in care homes was required.
9.
Prescription issued for patient as a repeat. The drug required more detailed monitoring as it should
have ideally been issued by the hospital. The dosage was also queried.
The review concluded that prescriptions for acute and repeat items should be separated
when presented to the GP’s for signature, to alert them of the difference. Items deemed to
be incorrect within a patient records should also be deleted with immediate effect to ensure
errors are not repeated.