Adult Safeguarding - Raising a Concern and the Decision Making Tool (DMT)

 MK Together has developed a Decision Making Tool to make it clearer and easier for people to understand what a safeguarding concern is and what to do with a concern.

Neglect and Acts of Omission – Medication Errors

Where an adult is given someone else’s medication, given too much or too little of their own medication, given a medication that has been stopped, or given it at the wrong time.

RESOLVE:

  • Isolated incident where the person is accidentally given the wrong medication, given too much or too little medication or given it at the wrong time but no harm occurs
  • Isolated incident causing no harm that is not reported by staff member
  • Isolated prescribing or dispensing error by GP, pharmacist or other medical professional resulting in no harm

CONSULT:

  • Recurring missed medication or errors that affect more than one adult and result in actual or potential harm to one or more adults
  • Isolated medication error that causes actual harm or ill health
  • Recurring prescribing or dispensing errors by GP, pharmacist or other medical professional that affect more than one adult and/or result in harm to one or more adults
  • Covert administration if the person lacks capacity without having a best interest decision recorded in the care plan
  • Misuse of/over-reliance on sedatives and/or anti-psychotropic medication to control behaviour

REPORT:

  • Deliberate maladministration of medications or failure to follow proper procedures, including reporting of medication errors
  • Pattern of recurring errors or an incident of deliberate maladministration
  • Deliberate falsification of records or coercive/ intimidating behaviour to prevent reporting
  • Insufficient or incorrect policies and procedures in place

Incidents meeting the lower level criteria should, wherever possible, be addressed at a local level with the individuals and professionals concerned with the aim of promoting positive relationships and an open culture which addresses the underlying issues. Repeated error making is also a warning that due care is not being taken, even if none lead to significant harm.

Last Updated: 29 July 2021