Victor Hall
16 Oct 2019 · Coroner Rachel Syed · Manchester (West)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. Phosphate Polyfusor product design
“one of the root causes for the medication error, was the Phosphate Polyfusor product design”
2. Polyfusor product design
“Product design on the Polyfusors in question”
3. failure to verify medication name before administration
“Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient”
4. inadequate medication transfer verification process
“system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient”
5. insufficient staff competency monitoring for medication verification
“Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
This report
“The Pharmacy and Nursing Matron [name redacted], concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label.”
Responses
2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust.pdf ↗· Medicines and Healthcare products Regulatory Agency
Stated action · immediate effect
“Introducing library conditions within the dispensary. Commencing with immediate effect.”
Stated action · 31st January 2020
“the exit route (after 5pm) from the 31st January department which is currently located next to the 2020 accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare”
Stated action · 29th February 2020
“Reviewing the layout of the dispensary with the aim 29th February of separating the areas used for different parts of 2020 the dispensing process and improving the flow of work.”
Stated action · 30th June 2020
“closed loop dispensing" (linking the 30th June 2020 electronic prescribing system to the pharmacy dispensing system and robot) with the aim of reducing dispensing errors and improving efficiency and therefore reducing the number of staff needed in the dispensary”
Stated action · 31st December 2019
“Updating the accuracy checking procedure which 31st December will incorporate a second check for all intravenous 2019 fluids.”