NHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals.
The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
Did you know?
Key causes of anti-infective medication error claims:
- Failure to check allergy status.
- Failure to cross-check the ingredients of a medication against allergy status.
- Failure to adjust dose of medication to the patient’s weight.
- Failure to adjust dose of medication according to renal function.
What can you do?
- When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring.
- Refer to the traffc light system for antibiotics and penicillin allergy.
- Ensure that the weight of a patient is regularly checked and adjust drug doses accordingly. • Check the allergy status of the patient at each point of the medication process.
- Review local guidelines to ensure they incorporate national guidance and support clinicians to prescribe, administer and monitor the effects of anti-infectives appropriately. Examples of relevant national guidance include NICE quality standards on on antimicrobial stewardship and sepsis.
- Access the NICE guidelines on acute kidney injury to fnd information and advice on the prevention, detection, and management of acute kidney injury.
- Review your organisation’s claims history regarding medication errors and ensure that learning is shared with clinicians.
NHS Resolution: Did you know? Anti-infective medication errors leaflet (16 August 2022) https://resolution.nhs.uk/wp-content/uploads/2022/08/Did-you-know_-Anti-infective-medication-errors.pdf
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