Dealing with and recording a medication incident
Service providers are responsible for monitoring patterns of medication incidents and errors.
This responsibility includes reporting errors to the relevant medical practitioner, ensuring the advice of the medical practitioner is followed in addressing an error, documenting any errors on the resident’s medication records and ensuring processes are in place to minimise the risk of continued or future errors.
- where the medical practitioner’s advice or instruction involves a change to the original medication schedule, the advice or instruction is expected to be in writing.
- where it cannot be provided in writing, it should be verbally confirmed by the medical practitioner with either the service provider or staff member. A second service provider or staff member should repeat the instruction back to the medical practitioner for confirmation of accuracy, and request confirmation from the medical practitioner in writing as soon as possible thereafter.
- a written record of the verbal advice from the medical practitioner should be made as soon as possible by staff members in the resident’s medication record and in staff communication notes used within the service. If a new prescription is required, the medical practitioner’s oral instruction must be to the pharmacist who will be dispensing the medication.