HSIB investigation reveals complexity of medicine safety

The MDU is making members aware of the recommendations of a review into a drug administration error.

A review of an error in administering a medication in the wrong formulation to a child found there was a lack of knowledge among some staff of the medicines being used and that safety systems were bypassed.

The review was carried out by the Healthcare Safety Investigation Branch (HSIB), the body which focuses on learning from incidents. The HSIB recommends that there is a national standard for the administration of certain high risk medicines and improved safety measures and training around prescribing.

National complexity of medicine safety

In the case leading to the review, a child who had been admitted to hospital for a day case procedure, an oral suspension of Midazolam was inadvertently injected via the IV route. This was despite the doctor and nurse following a two-person checking process used to ensure that the correct drug and dosage was administered in the correct way.

While the drug and its dose was checked, the doctor was not aware that the nurse had drawn up the oral suspension into a syringe specially designed for enteral use, rather than the IV preparation. Both the oral and IV preparation of the drug were stored next to each other in the controlled drugs cupboard.

The syringe was handed to a second doctor, who was performing the procedure. However, this doctor could not connect the enteral syringe to the IV line as they were incompatible and requested that the medication be transferred to a 'normal' IV syringe. The doctor realised that this was the wrong drug on IV administration as it was noted to be sticky and smelled sweet. The patient did not suffer any adverse effects but did remain in hospital to be monitored.

HSIB investigation, findings and safety actions

The HSIB was made aware of the incident via the national reporting and learning system.

As well as looking at how medicines are stored, prescribed, prepared and checked, environmental and human factors were also considered. The investigation highlighted the lack of knowledge of the medicines being used by inexperienced nursing staff and unfamiliarity with enteral syringes by medical staff more widely.

The decanting of the medicine from enteral to Luer lock syringe also bypassed the physical safety barriers that are put in place to prevent these errors occurring. The investigation highlighted other issues including the lack of adherence to local medicines policy and the lack of a local safe sedation policy for children.

Some of the findings of the report have implications for the training of medical students and qualified doctors in the preparation and administration of oral and IV medicines. The review also found variable practices across healthcare facilities about storage of medicines and syringes.

The HSIB's full recommendations and safety actions are available in the full report.

About HSIB

The Healthcare Safety Investigation Branch (HSIB) is a relatively new organisation whose focus is to promote learning from clinical incidents across the healthcare system, rather than apportion blame. The MDU has advised a number of doctors who have been asked to take part in its investigations. More information can be found in the MDU's journal.

This page was correct at publication on 29/04/2019. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Dr Kathryn Leask

by Dr Kathryn Leask BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM MRCPathME DMedEth MDU medico-legal adviser

Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and deputy chief examiner for the faculty. Kathryn is currently a member of the faculty’s training and education subcommittee and a member of the Royal College of Pathologists (medical examiner).