65 The nurse on duty on the 13.07.2021 confirmed that the dose had been missed. As soon as the error was noticed the correct action was taken; blood tests were taken to confirm the correct dose. A Dr spoke with Mr X and explained that no harm would have been caused. Mr X confirmed that he was aware that he had not been caused any harm. What action will be taken as a result of this enquiry to include formal/informal action taken with the organisation and or adult(s)? Please include any learning and recommendations. The Matron for the ward has apologised to Mr X for the error and reassured him that he would not have suffered any harm. The Matron has also advised MR X that the staff member has been identified and the error will be addressed with her. The matron also shared that changes in how the medication round are completed have been implemented so that this shouldn’t happen again. Flo has attended a medication refresher and has had her competency reassessed Organisation-Shared learning with the matrons. Learning will also be shared organisation wide so that changes to medications rounds can be implemented across the organisation. Suggested learning/recommendations: Use of red tabards being shared at matron’s meetings so that they can be implemented across other clinical settings if appropriate to do so. Are there any continuing risk factors for the adult at risk/ others If so what actions will be taken to minimise these risks? No continuing risks to Mr X. Risks to other patients have been reduced significantly. The ward has introduced a red tabard to be worn by staff administering drugs so that other staff, patients and relatives know that they shouldn’t be disturbed unless there is an emergency Have the contents of this report been discussed with the adult at risk or their representative Yes No If yes, who was informed and what information was shared? Did they express what they wanted to happen Yes No If yes, what was requested If no, please state the reason why not e.g. lack of capacity, coercion or duress, additional risk factors etc.
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